Child

David H. Munger

George W. Butz

Kaupp

Medins

Silen

Summers

Thomas E. Starzl

English

PubMed

Crossref

Starzl, Thomas E

Butz, George W

Munger, David H

D-Scholarship@Pitt

A Technique for Portacaval Transposition T H O h l A S  E. STARZL,  M.D., GEORGE W. BUTZ, JR., M.D., AND DAVID H. XfUNGER, B.S., Northwestern University Medical School Since its clescription by Child1 in 1953, porta- caval transposition has proved to be a versatile tool for studying various aspects of hepatic and gastrointestinal physiology. With this prepara- tion, the effects of diverting the splanchnic drain- age away from the liver can be assessed without the complicating factor of deterioration of hepatic . function.' Two factors have reduced the experimental value of portacaval transposition. The first of ' these involves the ligation of tributary vessels to the portal vein or vena caval in order to obtain greater mobilization for the anastomoses. The  . resultant alteration of the adrenal, pancreatic or duodenal venous drainage could influence ~ r i -  ous parameten to be measured. The  second factor involves technical difficulties5 which are related to the need for portal obstruction during trans- position of the vessels. In the present study, a simple technique is out- lined with which acute portal or cam1 hyper- tension is prevented during operation, and with which none of the portal or vena caval branches are ligated. A high rate of success has been at- tained, without transfusions, intravenous fluid therapy or other care. An 8 to 10 mm. portacaval anastomosis wa, performed as far below the pancreatic vein possible (Fig. 1, B) without excision of tissue from either vessel wall. The femoral-jugular external polyethylene bypass described by Kaupp war then inserted and the portal vein and inferior vena cava occluded with Potts clamps above and below the proposed site of transposition (Fig. 1, C). The anastomosis of the distal portal vein to the proximal vena cava was performed fint with 6-4 continuous arterial silk (Fig. 1, D). The distal vena cava was then connected to the proximal portal vein (Fig. 1, E). The posterior row was placed from within the vessels. At first, thex anastomoses were difficult because of the short segments of vessels and the confined space of the operative field. After a few trials, these difficulties were eliminated. After completion of transposition, the external polyethylene bypass was removed and the ex. ternal jugular and femoral veins ligated. The preliminary side-to-side portacaval shunt was drawn into the jaws of a partially occluding Potu clamp, divided, and closed with continuous 6-0 silk (Fig. 1, E). TECHNIQUE RESULTS Twenty-two mongrel dogs, from 13 to 25 kg., were anesthetized with pentobarbital sodium. An The external bypass which decompressed both upper midline incision was made (Fig. I ,  A). The the portal vein and vena cava afforded excellent vena cava above the adrenal veins was mobilized. pmtettion to the gasvointestinal mcL The bowel T h e  portal vein was cleaned and mobilized above remained pink during transpit ion of the the entrance of the pancreatic vein (the highest vessels. Transfusions or fluids were not given tributary of the portal vein) to the bifurcation during or after surgery- The do@ wen  albwed to in the liver hilus. The proximal 1 cm. of the eat the day after operation, and no subsequent pancreatic vein was also mobilized. care was reauired. From the Depariment of Surgery, Northwestem Uni- In the d;velopmental stages of this technique, utrsity ~ e d i m l  school, chiago. difficulties were encountered with the anas- n k  wort w u  rided a grrnt h ~ m  the Amaimn moms, which had to be performed with short H a r t  Assodrtion aod Cnnt A-3176 h the US. Public venous cuffs. In three of the fint five experiments, H a l t h  Serria. Natioad Imtitutcl d Halthe -& p m l  anastomotic thrombosb s u b  Maviand. Dr. Sturl n a Markle Scholar. Paper submitted for publleath April 17. 1961; accepted qutn*y8 l7 tnns~ositiOns were per- Mar 5,1961. formed with long-tam survival. JSR - VoL I, No. 3 - September, 1961 ' Thr tion I and a dogs I for tw dogs I weigh At : three r the ar and tk  no an: h i s  ( of fen into ti volved "OF Pact a. 5 was :in as : from ternal was ferior e and (Fig. to the th 6-0 distal wimal v was these short lf the ultia ern a l e ex- The was Potu '\ both 4ent owel the ;iven ed to uent ique, asto- ihort ents. - -1bSe- P I . ~ s R  - Yol. I ,  No. 3 - September, 1961 A TECHNIQUZ FOR PORTACAVAL TRANSPOSITION 219 i Fig. 1. S t q n  in the technique of portacaval tmnsposition. The studies for which the portacaval transposi- tion was performed were carried out from one md a half to eight weeks after operation, and the dogs were sacrificed. Weight loss was consistent br two or three weeks after operation, but all the dogs followed for one month or longer gained weight up  to or toward the preoperative level. At autopsy, the anastomoses were examined. In three of the first five animals, clots had formed at the anastomosis between the distal portal vein and the proximal vena cava. In the last 17 dogs, ao anastomotic thrombosis was prrxnt  Throm- bosis of the iliac vein w u  present above the site d femoral vein ligation, sometimes atending into the lower vena cava, but edema of the in- volved leg was not seen. In the chronic a imah ,  lo gross abnormalities .of the gaaaointestinal bza w u e  found. DISCUSSION Apparently, most of the difficulties during and after portacaval transposition have been due to shock. Transfusions have generally been neces- sary.'. 6 Summers5 has reported that irreversible shock with hemorrhagic gastroenteritis was com- monly seen even when the technique of opera- tion had reached a high degree of perfection. He suggested that exposure of the diverted adrenal venous flow to the detoxifying influence of the liver caused a state of adrenal insufficiency. In support of this contention was the fact that pro  and postoperative steroid therapy resulted in a seiLing reduction in operative mortality.6 The unifonn success with the wthod d o  scribed in the prcsent study and futtber experi- e n a  in Eiseman'r labontorpa provide widena that acute a d d  insufFaenq das  not occur as -- -- -  -- -- - 220 STARZL, DUTZ, and ~ I U N G F . R  JSR - Vol. I ,  No. 3 - Scptcmber, 1961 I a rcstrlt ol tlic tr;itislmsi~ion pcr sc. R;~rlicr, it sug- gests that the problems of fluid tllcrapy and hypo- tension are the result of depletion of the circu- lating blood volume by sequestration in the acutely obstructed portal and caval venous beds, and by continued fluid loss in these areas even after the obstruction is relieved. When such o b  struction is avoided during the operation, as has been described, no shock problems are encoun- tered, and the operative mortality approaches zero. SUMMARY A technique is described for portacaval trans- position in which portal or inferior vena caval hypertension is prevented by a decompressing external bypass during the period of vascular anastomoses. Successful preparations were uni- formly attained without transfusions or fluid therapy, and with a minimum of postoperative care. The method allows transposition without ligation of tributary branches of either the vena cava or portal vein. ADDENDUM Recently, an alternative technique for tramp sition has been used, based on the observation by Medins and LaufmanQf the protective action d hypthermia during mcsentcric vein O C C I U ~ ~ ~ ~ .  The animals are cooled to SO0 C. and the traw position perfomcd as described above with om& sion of the portacaval shunt and external bypas. In experiments in which it is desirable to l a w  intact femoral veins for subsequent testing, thh modification is the method of choice. REFERENCES 1. Child, C. G., 111. Barr, D. 8, Holsmde, G. R, and Harrison. C. S.: Liver regeneration following porn. caval transposition in dogs. Ann. Surg., 138:600. 1952 Z Ekeman, B.: Personal communication. 3. Kaupp, H. A, Jr., and Stanl. T. E.: The use of p external by-pw in utpcrirnrntll total hepatedoq. Surgery. f8:330, 1960. 4. Silen, W., Mawdslq, D. L.. Weirich. W. L, Harpa, H. A., and McCorkle. H. J.: A ampariron of lim funaion following Eck hstula and porn-crval tram position. Surg. Forum, 7:425.1956. 5. Summm. W. B.. Malette. W. G, and Ekeman, k Metabolic effecu of transposition of the portal vch and inferior vena can. Surg. Forum, 2429. 1956. 6. Medim, C, and Laohm. H@c_rfpia in meb taic Prteri?l and m o w  ocdnrim. -dl. AM. Suxg., N8:747, 1958. - i Pat ren tior is t a F Pas act] hor Ott effo gog tior was and tha Trc fror allc and blot of 7 hy F aff e tior and site - Fr lola 

A Technique for Portacaval Transposition.

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A Technique for Portacaval Transposition.

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