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The diagnostics and surgical treatment of liver cirrhosis complications.


Author: Anghelici Gheorghe
Degree:doctor habilitat of medicine
Speciality: 14.00.27 - Surgery
Year:2008
Scientific consultants: Vladimir Hotineanu
doctor habilitat, professor, State University of Medicine and Pharmacy "Nicolae Testemitanu"
Constantin Ţâbârnă
doctor habilitat, professor
Institution:
Scientific council:

Status

The thesis was presented on the 16 April, 2008
Approved by NCAA on the 19 June, 2008

Abstract

Adobe PDF document0.77 Mb / in romanian

Thesis

CZU 616.36-004:616.149-008.341.1[-0.89.168-06+616.149.1+ 616.145.7] -007.64-005.1-02-08

Adobe PDF document 10.10 Mb / in romanian
254 pages


Keywords

hepatic cirrhosis, portal hypertension, portal hemodinamics,esophageal and gastric variceal bleeding, endoscopic hemostasis, ascites, thoracic lymphatic duct, splenomegaly, hypersplenism, splenectomy, azygo-portal disconnection

Summary

Variceal gastro-esophageal bleeding, massive asites & progressive hypersplenism remains one the most actual problems in surgical treatment of liver cirrhosis.

The research has been conducted aiming at optimizing the methods of diagnostics, the pathogenetc argumentation and the improvement of results in surgical treatment of complications in liver cirrhosis portal hyperthension.

The research is based on the analysis of author’s clinical materials, which include 638 patients with diverse liver cirrhosis complications (esofago-gastric variceal bleedings – 252, resistant ascites – 168, splenomegaly with progressive hypersplenism - 218) who have been operated on from 1983 up to 2006.

The ultrasound dopplerflowmetry was used to study the main parameters of portal blood circulation with patients who suffer from liver cirrhosis in comparison with healthy people and the correlation with the functional liver reserves. It has been found out that the hyperdynamic situation of portal hemodynamics is due to the significant increase of splenic blood flow which is accompanied by the redistribution of blood into the inner branches of the portal vein, by the circulatory overloading of the left side of the liver and by the stealing of the right side of the liver.

It has been stated that while the liver functional reserves decrease, the vessel resistance and the stagnation of the portal blood flow together with the simultaneous decrease of the index of perfusion increase. The characteristics of the portal haemocirculation in diverse complications of liver cirrhosis have been studied. The inconsistency of the varicose-enlarged veins of the oesophagus in the decompression of the portal basin, independent on to what degree they distend, has been established.

The role of portal thrombosis in the development of liver cirrhosis complications has been specified, its interconnection with the level of gravity of complications and the worsening of the illness, has been revealed. It has been proved that the inversion of the portal blood flow constitutes an objective sign of the danger of the portal thrombosis and correlates with the level of decompensation of the liver functions.

The endoscopical method of the fibrin-glue haemostasis has been worked out and its high effectiveness in cases of haemorrhages from the varicose-enlarged veins of the oesophagus and the stomach has been applied. The close connection between the time haemostasis was reached place from the moment the haemorrhage began and the level of mortality rate has been established. At the same time, it has been proved that is haemostasis takes place during the first 12 hours then the mortality rate practically doesn’t depend on the reserves of the liver functions, whereas a more delayed haemostasis is accompanied by the thrice as much mortality rate which can be three times higher. The necessity to obliterate all the venous-enlarged veins aiming at the prevention of further haemorrhage relapse has been grounded.

The importance of portal gastropathy in the occurrence of haemorrhages with the patients suffering from liver cirrhosis has been confirmed and the method of its treatment by using the complex systemic and local ozone therapy has been suggested.

On the basis of the worked out method of the isotopic transabdominal lymphoscyntigraphy, the characteristics of lymphocirculation of the patients with ascites have been studied. The specific features of the lymphocirculation of the patients who suffer from ascites were possible to be studied by using the isotopic transabdominal lymphoscyntegraphy method. A genuine conception of step-by-step segmentary lymphostream disorder has been suggested, which made it possible to motivate patogenetically the indications for operating the thoracic lymphatic duct. Taking into consideration the role of the lymphocirculatory disorders in increasing the ascites syndrome, the operation for decompressing the neck segment of the thoracic duct has been worked out and implemented. This generation made it possible to improve the results of the treatment and the growth of life quality of the patients suffering from decompensating liver cirrhosis.

The patients suffering from cirrhosis with splenomegaly and hypersplenism manifested considerable growth of spleen haemocirculation which was moving faster and in much more quantity than the portal one, a fact that proves the concept of the “splenic hydrodynamic pump” to increase the portal hypertension and which can serve as hemodynamic indication in carrying out the azygo-portal disconnection with splenectomy.

It has been proven that the azygo-portal disconnection with splenectomy effectively decreases the portal pressure and, while retaining the portal-hepatic blood circulation, contributes to bettering the functional reserves.

The role of the postsplenocthomic thrombocytosis in the genesis of the portal thrombosis, which contributes to the further development of liver insufficiency, ascites, haemorrhages and DIC-syndrome, has been proved and the corresponding measures in the prophylaxis and the treatment of these illnesses has been elaborated.

The algorithm of the step-by-step treatment of the liver cirrhosis complications, depending on the predominant pathologic syndrome has been worked out. The obtained conclusions and the worked out practical recommendat made it possible to improve the methods of diagnostics, to pathogenetically motivate the indications for the diverse means of surgical correction, to determine the best tactics and to improve the results in the treatment of the hypertensis portal complications of the liver cirrhosis.