62例肠腔房分流术治疗B-CS临床分析

目的 探讨肠系膜上静脉-下腔静脉-右心房人工血管"Y"型架桥术(简称肠-腔-房人工血管"Y"型架桥术)在混合型B-CS治疗中的应用价值.方法 对101例混合型B-CS病人中的临床资料进行对比研究,其中肠-腔-房人工血管"Y"型架桥术62例,脾静脉-腔静脉人工血管架桥术(简称脾-腔人工血管架桥术)26例,肠系膜上静脉-下腔静脉人工血管架桥术(简称肠-腔人工血管架桥术)13例.结果 肠-腔-房人工血管"Y"型架桥术62例(简称肠-腔-房组)手术后血小板数明显升高(P＜0.05).脾-腔人工血管架桥术26例(简称脾-腔组)和肠-腔人工血管架桥术13例(简称肠-腔组)手术后血小板数无明显升高(P＞0.05).分流前后三组门静脉压力变化情况:肠-腔-房组均下降(P＜0.05),脾-腔组和肠-腔人工血管架桥术组(简称肠-腔组)无明显下降(P＞0.05).术后进行1年的随访,三组肝性脑病发生率分别为3.2%(2/62)、0%(0/26)和0%(0/13),三组肝性脑病发生率之间的差异无显著性意义(P＞0.05).三组人工血管通畅情况,有效率分别为95.2%(59/62)、69.2%(18/26)和38.4%(5/13),肠-腔-房组与脾-腔组和肠-腔组之间的人工血管均通畅率比较有显著性差异(P＜0.05).结论 肠-腔-房人工血管"Y"型架桥术在降低门静脉和下腔静脉压力及控制上消化道出血方面达到了满意的效果,且可同时消除病人脾功能亢进.脾-腔人工血管架桥术和肠-腔人工血管架桥术在治疗混合型B-CS效果非常不理想,不能达到治疗效果.     

肠-腔人工血管架桥术在布-加综合征治疗中的应用

布-加综合征(BCS)的治疗包括针对病变隔膜的手术、分流术、转流术和联合手术等方法,肠-腔人工血管架桥术是分流术的一种术式,在我们所治疗的1360例BCS患者中,采用肠-腔人工血管架桥术192例(14.1%),术后患者恢复顺利,平均随访(6.6±1.2)年,总有效率91.7%(110/120),血管通畅率为92.5%(100/108)[1]。本文结合文献,就肠-腔人工血管架桥术的手术方法、适应证、手术并发症的防治等介绍如下。一、手术方法全身麻醉,平卧位,左上腹部旁正中经脐下绕至右下腹旁正中切口进腹腔。吸尽腹水,探查肝、脾等。自大网膜静脉测自由门静脉压力(FPP),取肝组织…     

高位肠-腔人工血管架桥术联合门奇断流术治疗门脉高压症疗效观察

目的探讨高位肠系膜上静脉-下腔静脉人工血管架桥术(简称高位肠-腔人工血管架桥术,HMCS)联合门奇断流术治疗门脉高压症的疗效。方法对2001—2011年收治的144例行高位肠-腔人工血管架桥术联合门奇断流术门脉高压症患者的临床资料进行回顾性分析。结果全组男89例,女55例;年龄19～55岁。肝炎后肝硬化119例,其他肝硬化25例。均有中-重度胃底食管静脉曲张。有1次以上出血史者128例。术前肝功能分级:Child A级86例,B级58例。均行HMCS+断流术。术后自由门静脉压力平均下降9 cmH2 O。白细胞及血小板计数均明显升高或恢复正常。术后并发症:切口感染4例,腹腔感染1例,发热12例,肝性脑病2例,人工血管内血栓形成1例,出现乳糜漏14例,以上并发症均通过非手术治疗治愈。1例死于肝肾综合征。随访106例患者6个月至10年,其中95人自觉比术前明显好转,无消化道再次出血、肝性脑病、腹水等症状,总有效率89.6%(95/106)。肝性脑病4例,人工血管内血栓形成3例,均通过非手术治疗治愈;上消化道出血复发4例,其中死亡3例,1例通过非手术方式止血治愈。结论高位肠-腔人工血管架桥术联合门奇断流术治疗门脉高压...     

重症布-加综合征的治疗(附95例报告)

目的　 探讨重症布 -加综合征 (BCS)的治疗方法。 方法　 对 1994年 11月～ 1999年 6月收治的 95例重症BCS病人的临床资料进行回顾性分析。 结果　 手术治疗 75例 ,其中行肠腔静脉人工血管C型架桥吻合 5 1例 ,脾静脉与右颈内静脉人工血管架桥吻合 2 3例 ,肠系膜上静脉右颈内静脉人工血管架桥吻合 1例 ;介入治疗 10例 ,均行经皮肝肝静脉球囊导管扩张成形或 (和 )内支架放置 ;介入加常规手术 10例 ,经皮腔下腔静脉球囊导管扩张成形及内支架放置后行肠腔人工血管C型架桥术。除手术死亡 5例外 ,90例随访 6个月～ 5年 ,效果优者 6 5例 ( 72 .2 % ) ,良者 2 5例 ( 2 7.8% )。 结论　 对重症布加综合征病人应依据病变类型行相应的治疗方法 ,多数病人可取得良好效果     

成人门静脉海绵样变性的诊断和治疗

目的　探讨成人门静脉海绵样变性的诊断方法和治疗。方法　对 31例成人门静脉海绵样变性患者的临床资料进行回顾性分析。结果　 31例患者术前均有出血史 ,术前均经超声检查提示肝脏正常及门静脉海绵样变性 ,经脾穿刺门静脉造影或选择性肠系膜上动脉造影确诊。 12例行脾动脉结扎、胃冠状静脉及分支结扎、肠 腔C型架桥术 ,1例行脾 肾静脉架桥术。 8例已切脾断流后再出血患者 ,结扎冠状静脉主干后 ,6例行肠 腔C型架桥术 ,1例行肠系膜下静脉 下腔静脉C型架桥术 ,1例因静脉曲张和出血部位在空肠上段而行空肠节段切除术。 6例行脾 腔架桥术 ,2例行改良脾 肺固定术 ,脾 肾架桥术和门静脉 下腔静脉架桥术各 1例 ,1例行脾切除加贲门周围血管离断术。术后随访 6个月～ 4年 (随访率 10 0 % ) ,食管胃底曲张静脉均减轻或消失 ,无再出血和肝性脑病发生。结论　多普勒超声检查和经皮脾穿刺门静脉造影是诊断本病的理想方法 ;门 体分流术加门 奇断流术是治疗本病的最佳选择。     

小口径人工血管架桥门体分流联合贲门周围血管离断术治疗门静脉高压症上消化道出血

目的 探讨小口径人工血管(直径0.8 cm)门体静脉架桥联合贲门周围血管离断术在门静脉高压症(PHT)合并上消化道出血治疗中的应用价值.方法 对38例PHT合并上消化道出血患者采用小口径人工血管脾-腔架桥(14例)、肠-腔架桥(24例)联合贲门周围血管离断术治疗.结果 术后患者自由门静脉压力平均下降(6.6±1.2)cm H2O,手术前后肝功能相比差异无统计学意义(P>0.05).脾-腔架桥组术后外周血血小板和白细胞计数恢复正常(均P<0.05).手术死亡率为3%.术后并发症有发热4例,顽固性腹水和乳糜腹水各1例,肝性脑病1例,腹腔感染1例,应激性溃疡1例.除1例腹腔感染患者死亡外,其余经保守治疗后均痊愈.对35例进行了6个月至3年的随访,消化道出血复发2例,死亡2例,总有效率为89%.1年和3年人工血管通畅率分别为80%和75%.25例患者于术后6个月行纤维胃镜检查,食管胃底静脉曲张基本消失或减轻.结论 小口径人工血管架桥门体分流联合贲门周围血管离断术治疗PHT合并上消化道出血可明显降低门静脉压力,有效控制上消化道出血,肝性脑病发生率低.脾-腔架桥术可同时消除患者脾脏功能亢进.     

门腔静脉架桥分流术与侧侧分流术疗效比较

门腔静脉侧侧分流术治疗门静脉高压症胃底食道曲张静脉破裂出血，虽能有效降低门静脉压力，再出血率低，但因分流量大，术后脑病和肝功能衰竭的发病率高。限制性门腔分流术后大多数吻合口仍然会随着时间的推移而扩大，部分还可能因吻合口张力较大而最终发生狭窄或形成血栓。本文报告使用带外支撑环的８ｍｍ口径Ｇｏｒｅ－Ｔｅｘ人工血管行门腔静脉架桥分流术治疗门静脉高压症病人２５例，并与同期门静脉侧侧分流组１４例比较。结果显示门腔侧侧分流组门静脉压力下降数值稍大于架桥分流组，但两组比较没有统计学意义（１．０４±０．４４ｋＰａ和０．８７±０．２６ｋＰａ，Ｐ＞０．０５）。两组术后再出血率及手术死亡率差异无显著性意义，但门腔静脉人工血管架桥分流术后脑病发生率显著低于门腔侧侧分流术组（８．０％和３５．７％，Ｐ＜０．０５），术后经下腔静脉行门静脉造影证明人工血管通畅率为９６％。初步结果表明门腔静脉人工血管架桥分流术对病人创伤较小，操作简便，术后脑病发生率低，是一种值得推荐的治疗门静脉高压症的手术方法。     

重症布加综合征的外科治疗

目的 探讨重症布-加综合征的治疗方法。分析、评价肠腔静脉C形架桥、脾静脉-颈内静脉转流术对重症布-加综合征的治疗效果。方法 对1998年1月至2000年2月,作者收治的29例重症布-加综合征病人临床资料综合分析。结果 20例采用肠腔静脉C形架桥,随访2～25个月,其中17例效果良好(85％,17/20),3例症状改善(15％,3/20);9例采用脾静脉与颈内静脉转流术,随访2～25个月,其中5例效果良好(55.6％,5/9),3例症状改善(33.3％,3/9),1例死亡(11.1％,1/9)。结论 对重症布-加综合征病人,根据病变类型行肠腔静脉C形架桥术或脾静脉-颈内静脉转流术是有效的手术方式。     

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目的　探讨布 加综合征合理的临床病理分型、外科治疗方法及原则。方法　对 1983年 5月至 2 0 0 3年 6月收治的 136 0例布 加综合征病人的临床资料进行回顾分析。根据下腔静脉造影和经皮肝穿刺肝静脉造影 ,将其分为 4种类型 (6个亚型 ) :Ⅰa型 5 94例 ,Ⅰb型 12 3例 ,Ⅱ型 2 92例 ,Ⅲa型 2 37例 ,Ⅲb型 112例 ,Ⅳ型 2例。治疗方法包括 :(1)改良脾 肺固定术 2 6 5例 ,(2 )手指破膜或球囊导管扩张 4 0 7例 ,(3)根治性病变隔膜切除和血栓取出术 2 75例 ,(4 )下腔静脉旁路术 88例 (下腔静脉 下腔静脉架桥术 71例 ,下腔静脉 右心房架桥术 17例 ) ,(5 )肠系膜上静脉 下腔静脉C形架桥术192例 ,(6 )脾静脉 下腔静脉架桥术 32例 ,(7)脾静脉 右心房架桥术 2 3例 ,(8)脾静脉 颈内静脉胸骨后 5 7架桥术例 ,(9)肠系膜上静脉 右心房架桥术 8例 ,(10 )联合手术 6例 (包括 :肠系膜上静脉 下腔静脉 右心房架桥术 2例和脾静脉 下腔静脉 右心房架桥术 4例 ,(11)脾静脉 肾静脉分流术 4例 ,(12 )其他手术 3例 (包括肠系膜上静脉 颈内静脉架桥术 2例 )。手术死亡率 3 0 9% (4 2 / 136 0 ) ,并发症发生率 14 78% (2 0 1/ 136 0 )。结果　对 885例进行了随访 ,随访时间 9个月至 15年 ,平均 (6 8± 1 2 )年。总有效率为 89 4 %     

重症布-加综合征行脾静脉与颈内静脉转流术前后的血流动力学变化

作者为28例重症布-加综合征(Budd giarisyndrorme简称B-CS)患者施行了脾静脉与颈内静脉转流术,并用彩色多普勒显像仪观测手术前后下腔静脉,肝固有动脉和门静脉的血流量变化。结果表明脾-颈转流术有效的降低了门静脉压力,是重症B-CS理想的术式。     

Influence of the type of operations on the development of latex sensitization in children with myelomeningocele

Background

A genetic tendency to develop latex IgE responses in children with spina bifida has been suggested, but their degree of exposure to latex as well as the route and chronology for sensitization can be different from those of other children with multiple surgeries. The aim was to study the influence of the type of operation on the development of latex sensitization in children with myelomeningocele.

Methods

In 90 children with myelomeningocele operated with latex, data were collected about age, sex, family, and personal history of allergy, serum total IgE, presence of a ventricular-peritoneal (v-p) shunt, and number and duration of operations, classified as urological, orthopedic, on the v-p shunt, other neurosurgical, and others. A multivariate logistic regression analysis was performed, using the presence of latex sensitization as dependent variable.

Results

Serum total IgE, the number of urological and of orthopedic operations were synergistic variables to predict latex sensitization, together with the presence of a v-p shunt, but not the number of operations performed on this device. This seems to play an adjuvant role in the process of sensitization.

Conclusions

Not only the number, but also the type of operations, namely, of urological and orthopedic nature, is important in the development of latex sensitization in children with myelomeningocele.     

Operative treatment and prognosis of syringomyelia

Twenty-two patients suffering from syringomyelia were treated operatively. Different shunt procedures were performed. Most often syringo-subarachnoid shunt (seven cases) and syringopleural shunt (eight cases) were used. Operative findings and complications were discussed. Postoperative improvement was observed in five patients, twelve were stable-unchanged, four showed further deterioration and one died. Operative treatment should be performed before gross neurological deficit is established.     

Laparoscopic removal of dislocated ventriculoperitoneal shunts

In two patients the dislocated abdominal catheter of a ventriculoperitoneal (VP) shunt was successfully removed from the abdominal cavity by laparoscopy. Avoiding laparotomy, only two small abdominal incisions were necessary to insert the laparoscope and the grasping forceps. Postoperative course was uncomplicated except for protrusion of a part of the greater omentum through the umbilical incision in one patient. Both patients were mobilized on the operative day. Surgery required only 10 min, provided an excellent view of the entire abdomen, and led to prompt identification and removal of the lost catheter.     

Syringoperitoneal shunt for syringomyelia: A preliminary report

Syringoperitoneal shunting has been used in the treatment of 4 patients with idiopathic syringomyelia. The procedures have been performed without morbidity or mortality. Postoperative observation, ranging from 7 to 23 months, has not revealed progression of symptoms or failure of the shunt. The pathophysiological theories of syringomyelia are discussed, and various surgical procedures for syringomyelia are reviewed and their results compared to the effectiveness of the syringoperitoneal shunt.     

Avoiding the pocket: A case report of coiling of distal shunt catheter into subcutaneous pocket

IntroductionHydrocephalus is one of the most common disorders of neurosurgery and ventricular shunting, the primary surgical intervention, malfunctions in 85% of patients by 10 years.Presentation of caseHere we present a case of a 12-year-old girl with history of a vagal nerve stimulator (VNS) and ventricular shunt, most recently revised from ventriculoatrial (VA) to ventriculoperitoneal (VP) shunt at an outside hospital. The patient presented with a new left chest bulge, nausea, emesis, and seizures. Imaging revealed the patient’s distal shunt catheter to have completely migrated and coiled into the VNS subcutaneous pocket. Subsequently, the patient’s distal shunt catheter was externalized, and later internalized back to a VA shunt.DiscussionPotential spaces from previous surgeries such as VNS can lead to coiling of distal shunt catheters. In this case, the coiled distal shunt catheter led to hydrocephalus and the patient’s presenting symptoms.ConclusionIt is imperative to recognize patients with previous surgeries, especially those involving subcutaneous implants and to avoid passing of distal shunt catheters through these potential spaces.     

Comparison of Internal Shunts during Carotid Endarterectomy under Routine Shunting Policy

We compared patients who underwent carotid endarterectomy (CEA) using two-way and three-way internal shunts and discussed which shunt was more appropriate and effective for surgeons. Eighty-two patients (mean 69.5 ± 6.1 years old, mean degrees of stenosis 79.6 ± 10.4%) who had undergone CEA by our routine shunting policy were examined concerning the difference of Sundt and Pruitt-Inahara (P-I) shunts in clinical use. Carotid clamping time for the P-I shunt was over 2 minutes longer than that by Sundt in either split or conventional continuous arteriotomy (p < 0.001). The proportions of cases with multiple trials of either arteriotomy or insertion of a shunt tube, cases detected more than one high-intensity spot on diffusion-weighted images of magnetic resonance imaging after CEA, and cases detected postoperative intimal flaps detected by multi-detector CT angiography showed no significant differences between the two shunt groups. The two-way Sundt shunt was quicker than the three-way P-I shunt in placement with no remarkable problems. Split arteriotomy was not useful in shortening the placement time for either Sundt or P-I shunt tubes, compared with continuous arteriotomy. A simple two-way shunt with easy handling like the Sundt shunt would be also appropriate to choose in selective shunting under the unfamiliarity of treating shunts.     

Extrahepatic portal hypertension: a review of 70 cases.

Among 70 children with extrahepatic portal hypertension, more than 350 episodes of bleeding occurred. Of the 32 children who were not operated upon, six (19%) died of bleeding. Twelve children in the nonoperated group are thriving and well, although six of them have rebled 1-2 times. The operated group of 38 children had a total of 43 procedures. Central splenorenal and cavomesenteric anastomosis prevented further bleeding in 10 of 12 cases in which follow-up is available. Operative mortality was 24%, the majority of which were in emergency procedures.     

Arterial Shunt with Pump Infusion Line for the Treatment of Chronic Thoracic Aortic Aneurysms: The "Modified Shunt of Gott"

Dissection of the aneurysm is the most dangerous step during graft replacement of the descending thoracic aorta. Sudden hemorrhage may follow wall rupture or disruption of major collaterals before the aorta can be clamped. A simple modification of the classic Gott is illustrated, which makes the shunt work also as a partial bypass if needed, with rapid reinfusion of blood losses. Nineteen of 25 patients requiring resection of descending aortic aneurysms from 1982 to 1990 were treated with this method with no mortality.     

A comparison of the metabolic changes after the distal splenocaval and portacaval shunts

The distal splenorenal shunt (DSRS) is the recommended procedure for selective variceal decompression, but its use may be limited in patients who have undergone left nephrectomy, those with an anatomically aberrant relationship between the splenic and left renal veins, and those whose preoperative angiographic findings suggest a risk of developing postoperative renal vein hypertension. For these clinical situations, the selective distal splenocaval shunt (DSCS) is a useful alternative to the DSRS. However, the metabolic consequences of the DSCS have not yet been studied in detail and therefore, using a canine model, the metabolic changes following the DSCS and the portacaval shunt (Eck) were compared. The metabolic changes observed following the Eck were hyperammonia and amino acid imbalance, while those following the DSCS were similar to those of the control dogs. In terms of the hepatic adenosine triphosphate level, which reflects hepatic mitochondrial function, the DSCS dogs were also similar to the control dogs. These data suggest that there was no metabolic disadvantage of the DSCS compared to the control.     

Case report of migration of 2 ventriculoperitoneal shunt catheters to the scrotum: Use of an inguinal incision for retrieval,diagnostic laparoscopy and hernia repair

BackgroudVentriculoperitoneal shunts are commonly used in the treatment of hydrocephalus, and catheter migration to various body sites has been reported. Pediatric and general surgeons are asked on occasion to assist with intraabdominal access for these shunts, particularly when there may be extensive adhesions or other complicating factors.MethodsWe describe a case in which an old shunt catheter was never removed from the abdomen, and it migrated through an inguinal hernia into the scrotum. The catheter became entangled and fibrosed to the testicle. A second and more recent shunt catheter was also in the scrotum. A single incision in the inguinal region was used to remove both shunt catheters, repair the inguinal hernia and perform diagnostic laparoscopy to assist in placing a new ventriculoperitoneal shunt.ResultsPrompt surgical removal is recommended for catheters remaining in the abdomen after ventriculoperitoneal shunt malfunction. These catheters may cause injury to the testicle, or possibly other intraabdominal organs. General or pediatric surgical consultation should be obtained for lost catheters or inguinal hernias.ConclusionIn the case of an inguinal hernia containing a fractured shunt catheter, the hernia sac can be used to remove the catheter, repair the hernia and gain laparoscopic access to the abdomen to assist with shunt placement.