A technique has been described in which all the venous drainage of the deep femoral system is diverted through the hepatic bed by means of a reverse Eck fistula and systematic division of collaterals from the inferior vena cava and iliac veins. The use of this technique in the study of liver metabolism is proposed. Employment of simple reverse Eck fistula is suggested in clinical situations in which there is subdiaphragmatic destruction of the inferior vena cava. © 1959

Meyer, WH

Starzl, TE

English

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S U R G E R Y  -- - - VOL. 45 APRII,, 1959 NO. 4 Original Communications THE REVERSE PORTACAVAL SHUNT IV. 11. ~IEYER,  JR., i\.I.D.,* RIIAJII, FLA., AND T. E. STARZL, PH.D., BI.D.,** CHICAGO, ILL. (From tlrr IJrpnrtment of Surqery, The Uniz.er.eity of .Iliame School of Jledirine, and .Jarkson Jlemorlcrl Llospttal, Jlinmi, Fla.) I X A rcccnt study of hepatic metabolism in dogs,8 an  experimental prepara- tion was ~stnblished in which the cntirc deep femoral venous return passed through thc livcr. This was accomplishccl hy the formation of a side-to-side po~.tncnval fistula, ligation of the inferior vena cnva proximal to th r  atlastonlo- sis, :lnd rcniovnl of the caval and iliac collatcrnls. Rccnu~c! of  the potcntinl vi~luc of  thin proci~ilurc in ot,hrr ~tuclicn o f  livrr fnnction, thc rnc-thod will h(: ( l~s~r i l ) (v l .  Five mongrel dogs, approximately 10 Kg. in weight, were selected. Under sodium prntobarbital a~iesthesia the abdomen was entered through a long nppet. midline incision. The stomach and intestines were displacecl down and to the left. Adequate exposure of the operative site was obtained by upwart1 rctr:~ction of thc livcr after the thin mcscntcric vcil of  the caudate lot~c. w;is sc.ctionc~t1. ( F i g  I . )  The portal vcin and thc vena cava were pre- parrtl for  annstolnosis ant1 R prclirninary untied ligature WRS placrd around thc prosi111a1 cava. The slnnll bilc duct tributary that crosses thc portal vcin was avoitled. Thc anastomotic site was sclectcd well abovc the renal vcins and two guide sutures placed a t  least 1 cm. apart through the wall of both the portal vein and the inferior vena cava. The sutures were tied to  approx- imate the vessels and a modified Potts clamp" was positioned to provide partial occlusion of both veins. An elipse was excised from the wall of both Recelvefl tor publlcatlon Aug. 25. 1958. *Medical artlsf Edlth Tsgrln. Boaton. Mass. *U. 8. Publlc Health Tralnee No. ' 904. **Present sddrees: Department of Surgery. Northwestern Unlverslty School of Medlclne. Chlcago. IIL vclssclls :1111l the n ~ ~ : i s t o ~ ~ ~ o s i s  W:IS ~l:tr~~i(lcl 011t tv i t h  oflnlir111o11~ 5-0 arteri:~I silk (Fig.  1). The pa~vtinl occlusioll cl:tt1111 wns rc~llovcvl :1t1c1 t 1 1 ~  vcn;i c:lvn rvas tl1011 ticd and tr:~usrctotl well nhovc the cntrnncc of thc n~lrcnal veins. Wh~r l  tllc nnnstomosis wns ntlcquntc., t here was no tlistc~ntion of  thc clistnl vcna cava. Two to three wrrlts ;~ f t c r  surgery, dye sttltlirs were (lone by injecting 90 pcr cent Hypnquc sotlium into t,hc femoral vein. Orily n portion of the injected material rcachcd thc licpatic hccl. The rcmaindcr hypasscd the liver via extensive collnterals which originated from inferior vcnn cavn branches (Fig. 2). A second proccclurc was then done on three of the fivc dogs and all venous tributaries from the sitc of caval ligation through the hypogastric veins were divided with the exception of the renals. Dye studies two to three weeks after reoperation revealed that all material injected into the femoral vein passed directly through the anastomosis into the liver (Fig. 3). Inferior caval pressures in two dogs, obtained three weeks after the sccond procedure, were 140 and 160 mm. saline, respectively. I Fig. 1.-Artist's view of side-to-slde portacnval anastomosis In formatton of reverse Eck 1 fistula. DISCUSSION These procedures were not dctrinlental to the health of any of the five clogs. Oliguria, edema of the hindquarters, or ascites did not develop. Es- - cept for  .qn increase in prominence of the superficial veins of the abclominal wall, the dogs were indistinguishable from normal animals. Previous in- vestigators have described the absence of harmful sequelae after reverse Eclr fistula.'* S v  '* ' v  I t  is evident, however, from the present venographic studies that the usual reverse Eck fistula provides incomplete diversion of caval blood in wit ma aft ( ar I IIoI\- illto tlic portal syste111 (111r to tllc 1.npic1 tlcvrloprnrnt O F  systcvnic vcnorls c~oll:~tcr;~ls. Divisio~l of these collntc~~als was not attcn(lct1 1)y an incr.en.ucr1 I 111ol.l)itlity in tlic p r c s c ~ t  scrics. Sirlcc diversion of large qunntitics of systcrnic blood through the ~ ~ o r t a l  s?-stem is not injurious to liver f u n ~ t i o n , ~ .  impaired hcpatic metabolism in  I thc prcsent circumstnnces would be surprising. The absewe of any morbidity I or mortality is of w, however, inasmuch as th venous drainage I - Fig. 2.-Distrlbutlon of 90 per cent Hypaque durlng injeetlon lnto the femoral vein in a (log mlth reverse Eck fistula. Note the development of large systemle venous collaterals with resultant incornp!ete dlverslon of caval flow into the portal vein. The anastomosis Is marked with a n  arrow. Flp. 3.-Hypague lnjectlon lnto the femoral veln (same dog as Flg. 2 )  three weeks after  caval-Iliac strip. Note tha t  the entire dose of dye passes through the  anastomosls (a r row)  into the liver. w ~ v  s w  through the portal bed. I n  comment in^ on the difficultv of nh- taining survivors in portacaval transposition, Summers, Malette, and Eismanlo , h a v e  implicated the passage of endogenous adrenal hormones t h r o l s  hepatic parenchyma as the principal cause of death. The preeent findings 2---s- do not sumor t  this concept. ' l ' l i t> c l t ~ s ~ ~ r i l ~ t ~ t l  tt~t*Iiiiiq~ic~ 01' ; ~ l t t ~ t i ~ i g  the1 vrtiot~s i I i - ; t i r i i ~ ~ ( ~  o f  t t ~ ~  irtrrrior 11;111' 01' tlir 1)otly 1i;is ;~l)l)lic*i~tioii i r  thv c~spc~r i~~~c~nt ; i I  stli(ly of rrrtain 1)hnsc~n o f  Iit*l);itic* ttic~t;il)olis~ri. 01-(liri;i~.ily, wlict~ t-c~pt~;~tcvl iritml)ot.t:~l injcac*tionn o f  :illy sril)st:~ric~c ;ii.r clt~sit-1111. it is ~ict~c~ss;it.y to perforin ~riilltipl(b c~c~licltotriirs or s l ) l e ~ r i i c ~  puucat~ircs. IYitIi tlir pt.c~st~t~t prcy);lration, injoc~tions (.;In 1)c in;itlr iritn tlir 1t'g \-rills of th r  uiia~ic~stht~tixt'cl anirii:il anti all th r  ttintc*ri:ll will ~ : I S S  t111'1~11gll t o r rv~~r -so  14:cIi fist111;i into the liver I)ccl. For  such stntlit~s to 1111 \-:ilitl it is ~tor.css;~l-y to illtrt-~.ul)t h r  rntirc. cilval collatt~~-nl (Figs. 2 ant1 Z ) .  It' tl(~sii-rtl. the ctrc.ct of  systt~tiiit~ vclious atlrniiiist~*atio~i can thcn I)c cnmparrtl in tllc s;llne (log by iiijcction of th r  s~ihstancr  into a forclirni) vcin. l'hc rolc of th r  l ivrr in thc physiology of hor~iioncs o r  other tlrugs can thus  bc con. vciiicntly stndictl. This mcthotl also affords a rncans hy which hcpatoxic drugs call be rcpeatcdly instillctl directly into thc  portal circulation in an ~ f f o r t  to produce cxperimeutal cirrhosis. I t  is interesting to speculate about the occasional clinical situation to which thc principal of caval-portal rerouting may he applicable. Thc most o1)vious possibilities would he neoplastic invasion of thc inferior vcna cava hrtwren the renal veins and  th r  diaphragm, or t r a~una t ic  injury in  this arca sc r r rc  enough to ncccssitatc sacrifice of a segment of the  \7csscl. It would bc tempting, under thcse circumstances, to anastomose the distal end of the  cava to the side of the portal vcin rather than accept thc high risk of failure of intprposirlg a rcplacemcnt vein graft. 11 technique has bcen drscribcd in  which all thc vcnous drainage of the deep femoral system is divcrted through the hepatic becl by means of a reverse Eck fistula and systematic division of collaterals from the inferior vena cava ant1 iliac veins. The use of this technique in the  s tudy of liver metabolism is proposed. Employrncnt of simple rcverse Eck fistula is suggested in clinical situations in which there is subdiaphragmatic destruction of the  inferior vena cam.  REFERENCES 1. Boggild, D. H.: Experiments in Insulin Administration Through the Portal  System in Dogs, Acts path. et  microbial. scandinav. 5: 118, 1928. 2. Cllild, C. G., 111, Barr. D. P., IIols\vade, G. R., and Harrison, C. 9.: Liver Regeneration Following Portacaval Transposition in Dogs, Ann. Surg. 138: 600, 1053. 3. Chiltl, C. G., 111: The Hepatic Circr~lntion and Portal  Hypertension, Philadelphia, 1054, \V. B. Sauntlers Co. 4. Grintllny, .J. H., an11 Bollrnan, .T. L.: Regeneration of Liver in Dog After Partial  Hepatectorny: Role of Venous Circulation, Surg. Gynec. & Obst. 94: 491, 1052. 5. Higgins, G. JI., JLann, F. C., anel Priestly, J. T.: Experimental Pathology of the Liver: Restoration of Liver, Arch. Path. 14: 491, 1932. 6. Jahnke. E. .T., Cooke, F. N., antl Seeley, S. F.: A Modified Pot ts  Bullilog Clamp for  Use in  Portacaval Shunts, SURGERY 33: 48, 1953. 7. JIann, F. C.: The Effects of Complete antl Partial  Removal of the  Liver, Medicine 6: 419, 1927. 8. Ifeyer, W. H., Jr., and Starzl, T. E.: The Effect of Eck and Reverge Eck Fistula on the  Carbohydrate and Insulin Metabolism of Diabetic and Non-diabetic Mgs .  In press. 9. Silen, W., Nawclsley, D. L., Mreirich, W. L., and Harper, H. A.: Studies of  p pa tic Function i n  Dogs With Eck Fistula or  Portacaval Transposition, A. M. A. Arch. Surg. 74: 964, 1957. 10. Summers, W. B., Malette, W. G,, and Eisman, B.: Metabolic Effects of Trannposition on the  Portal  Vein and Inferior Vena Cnva, 8. Forum 7: 429, 1956. c L. an ev re T- ar; 

The reverse portacaval shunt

Meyer Jr, WH

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The reverse portacaval shunt

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