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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1841_Библиотеки_им_академика_М_И_Перельмана.pdf
BENIGN CONDITIONS
173
that this can be done postoperatively, even when the shunt is difficult to locate
due to oedema.
In the neck, the aim is to place the tip of the shunt in the SVC just above its
entry into the right atrium. By laying the shunt on the outside of the patient in
its predicted course, this can be estimated and the catheter cut at that point to
a 45-degree bevel. It is essential that the pressure across the shunt is accurately
measured and appropriate and with the patient absolutely flat, the end of the
shunt is raised and lowered. Ascitic fluid will flow from the shunt and is allowed
to do so until the pressure difference across the shunt from its tip to the neck
incision is 4cm and at this point flow ceases and equilibrium is reached.
Fig. 3.68 The end of the
shunt is then inserted into
the jugular vein and
screened to check the
position. The tip should lie
in the superior vena cava
just above the right atrium.
Fig. 3.69 Pump position identified for future use by ‘tattooing’ the local skin
immediately over it.
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174
The jugular vein is then opened and the shunt inserted. A tie is used to
loosely hold the shunt in place and the patient is screened under X-ray control
to ensure the tip is appropriately positioned. When this has been confirmed
and the shunt assumes a gentle curve in the cervical incision, the neck and
abdominal wounds are closed in layers. Forty mg of frusemide is given
intravenously at the end of the procedure.
Postoperative care Postoperative care, particularly in the first 96 hours, is
very important and we have a strict protocol for this ( Table 3.4 ).
After 96 hours, the patients are allowed out of bed and home the following
day. They are encouraged to continue to pump the shunt at least twice a day
and continue to wear the elastic corset. With this regimen, many patients will
end up with a flat abdomen (especially if abdominal exercises are employed).
Some will end up with a low pressure but still distended abdomen. The shunts
will often function for a number of years and if there is any doubt about this
can easily be checked by duplex ultrasound which gives a clear signal when the
shunt is pumped.
Fig. 3.70 The final shunt
position.
BENIGN CONDITIONS
175
Oesophageal varices
Oesophageal varices are inevitable in patients with portal hypertension from
whatever cause. We generally do not treat varices prophylactically even if the
endoscopic appearances show that they are very prominent. If there is a clini-
cal suggestion of, or endoscopic signs of bleeding (cherry red spots, adherent
thrombus, and visible blood in the GI tract with no other obvious cause),
treatment is required (Carbonelli et al ., 2004 ).
Acute bleeding ( Figs. 3.71 and 3.72 )
With acute variceal bleeds, in addition to standard medical measures, the
options for treatment are sclerotherapy, banding, and balloon tamponade. We
prefer to avoid the use of oesophageal balloons and, where there is experience
in endoscopic management, this can usually be achieved (Triantos et al .,
2004 ).
Sclerotherapy ( Fig. 3.73 )
The patients must be resuscitated and the endoscopy performed in a head-
down position with good suction available. A double-channel endoscope is
essential as this allows suction while the cannula and needle are inserted and in
addition the bridge on the left channel provides useful manoeuvrability of the
tip of the needle.
After the endoscope is inserted, some time should be spent assessing the
bleeding and obtaining a good position. Forceful irrigation (power washers) is
very useful to clear blood and clots and aid the view. It must also be remembered
Table 3.4 Postoperative care of a peritoneo-venous shunt
General care
◆
Antibiotics and frusemide (20mg IV twice a day for 72 hours)
◆
Biochemistry is measured twice a day for 48 hours and daily to 5 days.
A clotting screen is performed daily (problems occur particularly with
ovarian cancer patients where large amounts of protein enter the
circulation)
Shunt care
◆
The patient is managed in bed with the foot elevated 15 degrees for
the first 96 hours. They only rise from the bed for short periods for
essential activities
◆
An elastic corset is worn around the abdomen and not removed
◆
All drinks are taken through a straw to reduce the intrathoracic
pressure and encourage flow across the shunt
◆
The shunt is pumped 10 times at 4-hourly intervals (throughout the
whole 24 hours) by the patient or a nurse. The tattoo facilitates
locating the chamber. This is sometimes uncomfortable but the
importance must be stressed
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Fig. 3.71 The management of variceal bleeding.
Suspected
variceal bleeding
Urgent resuscitation
airway protection
antibiotics
vasopressin
terlipressin
octreotide
Endoscopy
Fundal varices
Oesophageal
varices
Sclerotherapy or
banding
Cyanoacrylate
(thrombin)
Bleeding
controlled
Eradication
programme
Bleeding
continues
Balloon
tamponade
Shunt surgery or
devascularization:
consider
transplant
TIPS
Repeat
sclerotherapy
Controlled
bleeding
Bleeding
controlled
BENIGN CONDITIONS
177
Fig. 3.72 The management of recurrent or refractory variceal bleeding.
Recurrent or
refractory
Variceal bleeding
Non alcoholic or
stopped drinking
Transplant
candidate
Child–Pugh C
TIPS
Repeat
sclerotherapy
Transplant
Failure
Selective shunt
Surgery
Ascites minimal
Devascularization
Porto caval
shunt
Consider distal
selective shunt
Massive ascites
TIPS
SMV, PV
Thrombosis
Disease
progression
Child–Pugh
A or B
Good operative
risk
Poor operative
risk
Non cirrholic
alcoholic
elderly/unfit
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178
that even in patients with known varices up to 30% can bleed from another
source (gastritis, peptic ulceration, oesophagitis) if there has been no previous
variceal bleeding and up to 10% even when this has occurred (Silverstein et al .,
1981 ; D’Amico et al ., 2003 ; Gonzales et al ., 2008 ). When the bleeding varix or
varices are identified, then sclerotherapy or banding is used to treat the source
alone at this time. The patient is endoscoped the following day to repeat the
sclerotherapy and then treat any other varices.
We prefer Ethamolin® (ethanolamine oleate) to STD (sodium tetradecyl
sulfate) as it is more viscous, and inject into the varix. Previously we favoured
cyanoacrylate (especially for gastric varices), but while of proven efficacy it is
no longer available. Even with micturating varices using Ethamolin® the bleed-
ing stops in a very short time and we feel that STD is often washed away too
rapidly. When injecting, it is important to decide on the amount to be used
and the assistant who is injecting should be asked to count off the amount in
0.5 mL aliquots.
When the varix blanches, we remove the needle while still injecting in an
attempt to seal the needle track. Two to three mL for each varix are generally
required, with a total of 10–12mL. Waiting a short time and irrigating should
confirm that the bleeding is controlled and the endoscope can then be removed.
The plan is to eradicate the varices (which can usually be achieved) and we
always re-endoscope patients at regular intervals. This is initially done at
24 hours, a week, a month, 3 months, 6 months, and yearly thereafter.
Surveillance in this way enables effective variceal control in the majority of
Fig. 3.73 Intra-variceal
injection of sclerosant.
BENIGN CONDITIONS
179
patients, often for many years. The sudden appearance of new varices or diffi-
culty with sclerotherapy should alert one to the possibility of a further increase
in portal pressure and we would always reinvestigate these patients to exclude
the development of portal vein thrombosis or a hepatic malignancy.
Gastric varices ( Figs. 3.74 – 3.77 )
Gastric varices pose the same problems as oesophageal varices but are technically
more difficult to treat. We employ an aggressive approach using Ethamolin®.
Fig. 3.75 View towards
the gastro-oesophageal
junction showing the
endoscope surrounded by
gastric varices.
Fig. 3.74 Retroflexed
endoscopy looking
towards the gastro-
oesophageal junction.
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Fig. 3.77 Needle slowly
withdrawn while still
injecting to seal the tract.
Fig. 3.76 Injection sclerotherapy to all visible varices.
BENIGN CONDITIONS
181
The endoscope is inserted and a J-manoeuvre performed in the stomach
( Fig. 3.74 ).The bleeding can generally be seen easily as the blood runs down
and away but it is sometimes necessary to tilt the table to improve the view.
The varices run towards the cardia and the inserted endoscope and can usually
be easily seen.
We believe that this is much more effective than just injecting distally. With
gastric varices, unlike oesophageal, we also inject any other varices seen (1–3mL
each) to a total of 12mL. We will then repeat the endoscopy and re-inject the
varices on a daily basis until they are seen to thrombose (obvious clinically)
and from that point surveillance is the same as for oesophageal varices (Tripathi
and Hayes, 2008 ).
Balloon tamponade ( Figs. 3.78 – 3.80 )
Balloon tamponade is remarkably effective as a first aid measure in uncontrol-
lable bleeding from oesophageal varices. The original Sengstaken–Blakemore
(SBT) tube has been available for more than 50 years and with some modifica-
tion remains today (Sengstaken and Blakemore, 1950 ). The use of these tubes
has to be carefully monitored and a management plan for their removal in
place.
The original tube had three lumen with a large spherical gastric balloon
(variceal bleeding is from blood flowing in a cephalad direction), a long
cylindrical balloon in the oesophagus, and a gastric aspiration channel.
Fig. 3.78 Four-lumen tube
inserted transorally after
fully deflating the balloons
and liberal lubrication.
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182
Recent modifications (the modified SBT or Minneapolis tube) (Boyce, 1962 )
have an additional oesophageal aspiration channel to deal with secretions
above the oesophageal balloon which otherwise may be aspirated (especially
in patients where conscious level is depressed). These tubes are indicated for
patients in extremis where sclerotherapy has failed, and in ICU patients and
patients transferred into the unit where other forms of management have
failed and a further massive bleed must be stopped immediately. There are
problems associated with the use of balloon tamponade, including oesopha-
geal ulceration, continued occult bleeding, and recurrent bleeding after
removal of the tube. Careful and controlled use of these tubes is needed to
avoid these specific problems and we favour a four-lumen device. After check-
ing the balloons and ensuring that they are completely collapsed (the tubes and
ports are clearly marked gastric balloon, oesophageal balloon, gastric aspira-
tion port, oesophageal aspiration port) and the outside has been liberally
lubricated, we insert the tube orally.
It is inserted as far as possible and then the gastric balloon fully inflated (nor-
mally 300mL). The tube is then withdrawn and when resistance is felt, gentle
traction applied. At this point it is usually obvious that the bleeding has stopped
Fig. 3.79 Distal (gastric)
balloon inflated to 300mL
and gentle traction
applied. The oesophageal
balloon is then inflated to
half way between systolic
and diastolic blood
pressure.