THE RESULTS OF PORTOSYSTEMIC SHUNTING IN THE SURGERY OF PORTAL HYPERTENSION
F.G. NAZIROV, A.V. DEVYATOV, A.H. BABAJANOV
Republican Specialized Center of Surgery after academician V. Vakhidov, Tashkent, UZBEKISTAN
Introduction: The steady trend of increase of patients with liver cirrhosis (LC) complicated with portal hypertension (PH) has arisen by the end of the last century and persists today. Accumulated 35- year experience has allowed to revise a number of conceptual questions about the tactics of treatment of this category of patients, among them importance is given to correction of PH - to portosystemic shunting (PSSh).
Materials and methods: Different variants of PSSh were performed in 700 patients with portal hypertension in RSSC after akad.V.Vakhidov during the period from 1976 to 2010. Etiological factor of PH in 656 (93.7%) cases was liver cirrhosis (LC), 44 (6.3%) patients had extrahepatic form of PH, average age of the patients was 27,8 ± 11,9 years. In the structure of shunt operations the distal splenorenal anasthomosis (DSRA) has made 37.7%, proximal splenorenal shunt with splenectomy - 23.1%, latero-lateral splenorena l anasthomosis - 11.4%; splenosuprarenal anasthomosis - 11.0%, H-shaped splenorenal anasthomosis - 9.9%.
Results: Fatal liver failure was the main complication of the postoperative period, the remaining group of complications consisted of anasthomotic thrombosis with bleeding from esophageal and gastral varices (EGV). The rate of liver failure has made 16.9% after the central variants of shunting and 11.2% after selective anasthomosis. The frequency of thrombosis of anasthomosis - 5.0 and 3.6% respectively. At present against the background of prophylactic shunting with preservation of hepatorenal blood flow the rate of mortality in the immediate postoperative period has decreased to 3.2% in the central shunting and to 4.8% in selective decompression. In terms of 2-3 months after PSSh during the control endoscopy the regression of EGV was revealed in the majority of cases but decompressive effect was more pronounced in the central type of shunting rather than after selective DSRA.
Conclusion: Currently PSSh may surve both as a temporary measure for prevention of bleeding from EGA before liver transplantation, as well as the final treatment of this category of patients, including in countries where opportunities for radical surgical treatment of LC are absent for various reasons. The current stage of the development of vascular surgery of PH is characterized by individual approach to the selection of the best way for correction of this complication, which depends on the age factor, the risk of hemorrhagic syndrome, peculiarities of portal angioarchitectonics of the portal basin and the state of portal hemodynamics.
THE ANALYSIS OF THE QUALITY OF LIFE OF PATIENTS WITH LIVER CIRRHOSIS AFTER PORTOSYSTEMIC SHUNTING
Republican Specialized Center of Surgery after academician V.Vakhidov, Tashkent, UZBEKISTAN
Introduction: In modern surgery of portal hypertension (PH) portosystemic shunting (PSSh) keeps its priorities for the correction of this complication. In the scientific and clinical terms it is interesting to analyze the quality of life of patients with liver cirrhosis (LC) after PSSh.
Materials and methods: Analysis of the quality of life was conducted at 248 patients with LC after PSSh. Mean age of patients to the moment of surgery was 28,4 ± 4,7 years. Selective distal splenorenal anasthomosis (DSRA) was assessed in 135 (54.4%) patients. In the remained 113 patients different versions of the central shunting were carried out. For evaluation of the quality of life was used a questionnaire developed by Younossi ZM et al. (1999) for patients with chronic liver disease - The Chronic Liver Disease Questionnaire (CLDQ).
Results: Against the background of an effective decompression in the portal basin PSSh did not worsen the index of the quality of life of patients with the risk of hemorrhagic syndrome, but on the contrary, slightly increased its value. However, the progressive process in the liver contributes to the development of functional disability in hepatocytes which under conditions of adequate decompression is a major cause of fatal outcome. Regardless of the method of decompression in long-term period after PSSh the progressive deterioration in the index of the quality of life was most pronounced marked in the period from 1 to 3 years of observation (P <0.001). According to the scale of physical condition of CLDQ questionnaire the selective decompression differed with less significance to the central, and on the scale of psychological well-being and the subjective perception of the health found an opposite pattern with higher meanings after DSRA (74,2 ± 3,8% vs. 69,7 ± 4,1% - in terms of 3 months and 49,2 ± 5,7% vs. 46,6 ± 5,3% - in terms of more than 5 years, P <0.001), indicating a less pronounced manifestation of the syndrome of HE after selective decompression.
Conclusion: In patients with HE in the remote period after PSSh the progression of the pathological process causes the worsening of the quality of life (CLDQ) on the scale of the physical state from 78.6% (compared to the control - 100%) in terms of up to 3 months and to 55,3% (P <0.001) in terms of more than 5 years of observation, and on a scale of psychological state- from 72.4% to 48,8% (P <0,001).