[Surgical treatment of portal hypertension: the state of art].

The article highlights modern approaches to the treatment of portal hypertension. The differential tactics is based on the type of portal hypertension, functional liver state, urgency of the situation and severity of blood loss, localization and stage of varices, concomitant diseases, etc. The role of miniinvasive methods is stressed. The reasonability of general treatment algorithm of portal hypertention in specialized centers is proved.

[Combined operations for prophylaxis of gastroesophageal bleedings at the patients with portal hypertension].

Results of portocaval bypass (1st group), suture ligation of gastric and esophageal varicose veins (2nd group), and combined operations (3rd group) performed in early postoperative period at 759 patients with liver cirrhosis and extrahepatic portal hypertension are analyzed. Long-term results were studied at 549 patients. Early recurrence of bleeding was occurred at 41 (12.9%) patients of 1st group, at 17 (8.5%) of 2nd, and at 2 (4%) patients of 3rd group. Lethality due to bleeding recurrence at 1st group was 5.1% among the patients with liver cirrhosis and 1.9% among ones with extrahepatic portal hypertension. Recurrence of bleeding at 2nd group was seen at 52.8% patients with liver cirrhosis, and at 36.4% - with extrahepatic portal hypertension. Lethality due to bleeding recurrence in this group was 7%. The best results were achieved in 3rd group: the recurrence of bleeding was diagnosed at 2 (7.7%) cases, there was 1 lethal outcome. It is concluded that combined surgical procedures at the patients with portal hypertension permit to reduce the rate of early recurrences of bleeding in 2.5 times. It allow to perform widely the partial portocaval anastomoses at the patients with liver cirrhosis and the bypass procedures at extrahepatic portal hypertension.

[Late results of portacaval surgical shunt in patients with extrahepatic portal hypertension]. / Otdalennye rezul'taty portokaval'nogo shuntirovaniia u bol'nykh s vnepechenochnoi portal'noi gipertenziei.

Late outcomes of portocaval shunting (PCS) were analyzed in 135 patients with extrahepatic portal hypertension (EPH). It was established that the methods of choice in such patients should be splenorenal anastomosis, mesentericocaval anastomosis (MCA) "side by side" and H-type with autovenous or synthetic insertions. The best results were detected in a combination of portocaval anastomosis with the suturing pf stomach and esophageal varicose veins, if the diameter of the anastomosed vessel was small and portal pressure was reduced by less than 25% (100 mm of water column). The ineffectiveness of MCA "end in side" by Bogoras and cavamesenterial anastomosis was shown due to low efficiency and severe complications, respectively. These data demonstrate efficacy of endovascular dilatation in PCA stenoses, yet the possibilities of severe complications still exist. The best result of endoscopic PCS estimation 1 year after the surgery suggested complete recovery of patients with EPH in most cases.

[Surgical treatment of resistant ascites in patients with portal hypertension]. / Khirurgicheskoe lechenie rezistentnogo astsita u bol'nykh s portal'noi gipertenziei.

Surgical methods of treatment of diureticoresistant ascites in 198 patients with portal hypertension are analyzed: portocaval bypass (n = 16), lymphovenous anastomosis (n = 64), ductolysis (n = 24), and peritoneovenous bypass (n = 94). The most stable positive results was achieved after portocaval bypass, but it can be performed only in a small part of patients. Peritoneovenous bypass and lymphovenous anastomosis demonstrated shorter effect but they had less risk and were better tolerated than portocaval bypass. Efficacy of these surgeries depends not only on accurate indications and contraindications but also on functional resource of the liver and organism's reserves. Following these conditions and individual approach to choice of surgical methods of resistant ascites' treatment may improve quality of life and lifespan of patients with portal hypertension.

[The evolution of surgery for extrahepatic portal hypertension]. / Evoliutsiia khirurgii vnepechenochnoi portal'noi gipertenzii.

30 years' experience of elective surgical treatment of 600 patients with extrahepatic portal hypertension is summarized. Insufficient effectiveness of splenectomy in bleeding from varicose veins (VV) of the stomach and the esophagus (40% of relapses) is shown as well as frequent development (25%) of asplenic hemorrhagic thrombocytopenia. Partial esophagogastrectomy also has failed initial hopes due to severe agastric anemia which developed in 49.6% patients and relapses of erosion and ulcerogenous hemorrhage from the gastric stump (30%). Introduction of microsurgical methods, contemporary suturing material, usage of the jugular vein's segment for performing H-shape anastomoses enabled in the last decade to carry out porto-caval shunt using distal segments of superior mesenteric vein with diameter 5-9 mm and thus to increase the number of radical operations to thoroughly rehabilitate the patients, and to decrease postoperative mortality rate from 11.1% to 0.7% as well. Vascular anastomoses were not feasible, the operation of choice may be suturing of VV of the esophagus and the stomach with subsequent endoscopic sclerosis formation.

[Orthotopic liver transplantation (first clinical experience)]. / Ortotopicheskaia transplantatsiia pecheni (pervyi klinicheskii opyt).

The article deals with the results of work conducted according to the orthotopic liver transplantation (OLT) program from January 1990 to January 1992. To select the patients for OLT, 54 persons (24 males and 30 females aged from 12 to 55 years) with diffuse (34) and focal (20) diseases of the liver were examined. OLT was indicated for 19 patients who were registered in the waiting list. In the period of waiting for the donor organs, 5 persons died, 3 refused to undergo OLT, and 4 remain on the waiting list. Eight OLT (including one retransplantation) were conducted on 7 patients. The indications for OLT in these patients were: unresectable hepatocellular carcinoma (4), cirrhosis of the liver of viral etiology (1), fulgurant form of hepatitis B (1), transplant rejection crisis which could not be arrested (1). Immunosuppression was conducted by the two- and three-component programs with the use of corticosteroids, cyclosporine A, and azathioprine. Eight crises of transplant rejection were encountered, successful retransplantation of the liver was accomplished for one of two crises which could not be arrested. The survival of the operated on recipients ranged from 3 days to 15 months. Various complications (mainly hemorrhagic and infectious) were encountered in the posttransplantation period. At the time that the article is written, 3 patients are living for 15, 9, and 4 months (after retransplantation of the liver in the last case), their condition is satisfactory. The death of the other recipients was caused by candidosepsis (on the 40th day), polyorganic insufficiency (on the 10th and 3rd days), sepsis (on the 12th day). The results of the liver transplantation program correspond to those of transplantation centers in other countries in the period of OLT mastering.

[Study of central and porto-hepatic hemodynamics before the surgical treatment of patients with liver cirrhosis and portal hypertension]. / Tsentral'naia i portopechenochnaia gemodinamika pri khirurgicheskom lechenii bol'nykh tsirrozom pecheni i portal'noi gipertenziei.

Basing on the results of hemodynamic findings related to the heart and liver in 41 patients with hepatic cirrhosis and portal hypertension (33 of them were operated on for portal hypertension), it is suggested that when deciding on the type of surgery in such patients, initial status of central and portal hemodynamics as well as expected changes in these parameters due to surgery should be taken into consideration. Pathogenetic grounds for some routine interventions in hepatic cirrhosis and portal hypertension are thought open to question.

[X-ray intravascular reduction of blood flow along the hepatic artery in patients with portal hypertension and resistant ascites]. / Rentgenoéndovaskuliarnaia reduktsiia krovotoka po pechenochnoi arterii u bol'nykh portal'noi gipertenziei i rezistentnym astsitom.

After studying the results of embolization of the hepatic artery in 14 patients with portal hypertension and resistant ascites the authors came to the conclusion that this operation often leads to the development of hepatic insufficiency and a fatal outcome and produces a clinical effect only in a small number of patients. Celiac- and mesenteric angiography and transhepatic portography were carried out for pathogenetic substantiation of the intervention. Pressure in the portal vein, hepatic veins and arteries, and in the inferior vena cava was measured during the examination. The space velocity of the portal and arterial hepatic blood flow was determined. Clinico-angiographic examination of the patients failed to reveal criteria for predicting the efficacy of embolization of the hepatic artery. A positive result may be expected in cases in which embolization leads to a reduction in portal pressure. Embolization of the hepatic artery produced no clinical effect in initial reduction of the blood flow in the liver.

[Peritoneovenous shunt in resistant ascites in patients with portal hypertension]. / Peritoneovenoznoe shuntirovanie pri rezistentnom astsite u bol'nykh s portal'noi gipertenziei.

Experience in 100 operations for the creation of a peritoneovenous shunt in 63 patients with portal hypertension and resistant ascites showed that in careful selection of patients and determination of contraindications this operation is an effective method for the treatment of resistant ascites in patients with portal hypertension. The shunt increases diuresis, reduces the volume of the abdomen, makes laparocentesis unnecessary, improves the patients' general condition and allows some of them to be prepared for interventions on the organs of the portal system which are more radical in character.

[Surgical treatment of segmental extrahepatic portal hypertension]. / Khirurgicheskoe lechenie segmentarnoi vnepechenochnoi porta'lnoi gipertenzii.

The authors analyse the immediate and late-term results of surgical treatment of 39 patients who underwent 50 operations for segmental extrahepatic portal hypertension (SEPH). The threat of gastric hemorrhage was the main indication for surgery. Gastrotomy with suturing of the varicose veins of the stomach is the operation of choice when gastric hemorrhage continues. This operation produces an immediate clinical effect but fails to ensure long-term prevention of bleeding. In planned treatment splenectomy is the operation of choice only in patients with signs of marked hypersplenism when there is little threat of the development of asplenic thrombocytemia in the postoperative period. Separation of the vascular gastrosplenic connections is the operation of choice in the absence of hypersplenism. Ligation of the splenic artery and transposition of the decapsulated spleen into the retroperitoneal space have no haemostatic effect and must not be conducted for the prevention of gastric hemorrhage in this pathological condition.