Differentiated Surgical Treatment of Patients with Liver Cirrhosis and Portal Hypertension. Part II. Surgical Aggression and Pathogenesis of Postoperative Complications

Aim. To investigate the major risk factors and influence of surgical aggression on development of postoperative complications in surgical treatment of patients with liver cirrhosis and portal hypertension.
Material and Methods. Features of early postoperative period in 300 patients with liver cirrhosis and portal hypertension were analyzed. The groups of patients were defined where the influence of various technical aspects of operations on surgical results was studied. Also impact of changes of the main parameters of nutritionally-metabolic status, central and porto-hepatic hemodynamics, tissues’ “oxygen regime” on the development of postoperative complications was
assessed.

Results. An important role in the development of postoperative complications should be assigned to surgical technique, optimal design of the vascular anastomosis and composition of operations on the stomach. Surgery tolerance caused by baseline disease compensation. Surgical aggression reduces the reserve capacity deficit and compensation capacity on average by 10–15%. Under the influence of surgical aggression depending on the type of surgery and the initial severity of chronic liver failure the disorders in nutritionally-metabolic status, central hemodynamics, portohepatic circulation and some parameters of tissues’ “oxygen regime” may occur. Conjugation and mutual influence of “trophic homeokinesis”
violations carrying great responsibility in the development of postoperative complications were revealed. “Trophic homeokinesis” disorganization is the most important tool that provides pathological course of the postoperative period. The hypothesis and the universal scheme of pathogenesis’s common pathways of early postoperative
complications are presented.
Conclusion. Besides surgical techniques postoperative complications in patients with liver cirrhosis and portal hypertension are the result of non-compliance between initial severity of the disease, compensation of liver failure and level of organism’s reserve capacity on the one hand and requirements presented to organism by surgery on the other hand.

1. Kousin G.A. Korrekciya gomeostaza pri pishchevodnozheludochnyh krovotecheniyah u bol'nyh portal'noj gipertenziej [Correction of homeostasis in the esophageal-gastric bleeding in patients with portal hypertension]: dis. ... cand. med. sci. Moscow, 1987. 182 p. (In Russian)

2. Manuk'yan G.V. Enteral'noe lechebnoe pitanie u bol'nyh cirrozom pecheni s portal'noj gipertenziej [Enteral nutritional therapy in patients with liver cirrhosis and portal hypertension]: dis. ... cand. med. sci. Moscow, 1992. 207 p. (In Russian)

3. Umruzakov I.U. Nekotorye aspekty patogeneza recidivov krovotecheniya v rannem posleoperacionnom periode u bol'nyh portal'noj gipertenziej [Some aspects of pathogenesis of recurrence of bleeding in the early postoperative period in patients with portal hypertension]: autoref. dis. ... cand. med. sci. Мoscow, 1992. 25 p. (In Russian)

4. Barber J.R., Teasley K.M. Nutritional support of patients with severe hepatic failure. Clin. Pharm. 1984; 3 (3): 245–253. PMID: 6428797.

5. Muller M.J., Bottcher J., Selberg O., Weselmann S., Boker K.H., Schwarze M., von zur Muhlen A., Manns M.P. Hypermetabolism in clinically stable patients with liver cirrhosis. Am. J. Clin. Nutr. 1999; 69 (6): 1194–1201. PMID: 10357739.

6. Nachbauer C., Fischer J.E. Nutritional support in hepatic failure. In: Surgical nutrition. Boston, 1983. P. 551–565.

7. Eramishantsev A.K., Manuk'yan G.V. Today and tomorrow surgery of portal hypertension. Annaly khirurgicheskoy gepatologii. 1998; 2: 111–115. (In Russian)

8. Manuky'an G.V. Patogenez, profilaktika i lechenie oslozhnenij v hirurgii portal'noj gipertenzii u bol'nyh cirrozom pecheni [Pathogenesis, treatment and prevention of complications in surgery of portal hypertension of patients with liver cirrhosis]: dis. ... doct. med. sci. Moscow, 2003. 236 p. (In Russian)

9. Ambartsumian L.R. Osobennosti posleoperacionnoj reabilitacii bol'nyh cirrozom pecheni i portal'noj gipertenziej [Features postoperative rehabilitation of patients with cirrhosis and portal hypertension]: dis. ... cand. med. sci. Мoscow, 2009. 142 p. (In Russian)

10. Manuk'yan V.G. Vybor metoda operacii azigoportal'nogo razobshcheniya u bol'nyh cirrozom pecheni i portal'noj gipertenziej [The choice of method operations azigoportal dissociation in patients with cirrhosis and portal hypertension]: dis. ... cand. med. sci. Мoscow, 2011. 130 p. (In Russian)

11. Koshevoy A.P. Sovershenstvovanie diagnostiki i taktiki lecheniya bol'nyh s krovotecheniyami iz varikozno rasshirennyh ven pishchevoda i zheludka [Improving the diagnosis and treatment strategy in patients with bleeding from esophageal varices and gastri]: dis. … doct. med. sci. Мoscow, 2009. 412 p. (In Russian)

12. Shertsinger A.G., Manuk'yan G.V., Zhigalova S.B., Manuk'yan V.G. Pathogenesis formation of varicose veins tansformation of the esophagus and the stomach in patients with liver cirrhosis. Eksperimental'naya i klinicheskaya gastroehnterologiya. 2011; 6: 73–77. (In Russian)

13. Shertsinger A.G., Manuk'yan G.V., Zhigalova S.B., Manuk'yan V.G., Cherkasov V.A. Modification of the operation M.D. Patsiory in patients portal hypertension. Khirurgia. Zhurnal imeni N.I. Pirogova. 2012; 10: 9–13. (In Russian)

14. Eramishantsev A.K., Shertsinger A.G., Kitsenko E.A. Portal'naya gipertenziya. [Portal Hypertension]. In Saveliev V.S., Kiriyenko A.I., eds. Clinical surgery: national leadership. Moscow: GEOTAR-Media, 2009. P. 626–665. (In Russian)

15. Vianna A., Hayes P.C., Moscoso G., Driver M., Portmann B., Westaby D., Williams R. Normal venous circulation of the gastroesophageal junction. A route to understanding varices. Gastroenterology. 1987; 93 (4): 876–889. PMID: 3623028.

16. Sarin S.K., Lahoti D., Saxena S.P., Murthi N.S., Makwana U.K. Prevalence, classification and natural history of gastric varices. A long-term follow-up study in 568 portal hypertension patients. Hepatology. 1992; 16 (6): 1343–1349. PMID: 1446890.

17. Lebezev V.M. Porto-kaval'noe shuntirovanie u bol'nyh s portal'noj gipertenziej [Portocaval shunting of patients with portal hypertension]: dis. ... doct. med. sci. Moscow, 1994. 213 p. (In Russian)

18. Wolff M., Hirner A. Surgical treatment of portal hypertension. Zentralbl. Chir. 2005; 130 (3): 238–245. PMID: 15965877.

19. Luqman Z., Khan M.R., Alam M., Atiq M., Sophie Z. An analysis of surgical shunts for the management of portal hypertension at Aga Khan University Hospital. J. Ayub. Med. Coll. Abbottabad. 2004; 16 (4): 70–74. PMID: 15762069.

20. Bohyan T.S. Parcial'nye porto-kaval'nye anastomozy u bol'nyh cirrozom pecheni i portal'noj gipertenziej [Partial portacaval shunts in patients with liver cirrhosis and portal hypertension]: dis. ... doct. med. sci. Мoscow, 2000. 202 p. (In Russian)

21. Livingstone A.S., Koniaris L.G., Perez E.A., Alvarez N., Levi J.U., Hutson D.G. 507 Warren Zeppa distal splenorenal shunts: a 34 year experience. Ann. Surg. 2006; 243 (6): 884–892. PMID: 16772792. 22. Keohane P.P., Attrill H., Grimble G., Spiller R., Frost P., SilK D.B. Enteral nutrition in malnourished patients with hepatic cirrhosis and acute encephalopathy. JPEN. 1983; 7 (4): 346–350. PMID: 6413710.

22. Manuk'yan G.V., Eramishantsev A.K. Amino acid metabolism in patients with liver cirrhosis and ascites resistant. Rossijskij gastroenterologicheskij zhurnal. 1997; 4: 91–92. (In Russian)

23. Cascino A., Candiano C., Calcaterra V., Rossi-Fanelli F., Capocaccia L. Plasma amino acids imbalance in patients with liver disease. Am. J. Dig. Dis. 1978; 23 (7): 591–598. PMID: 685924.

24. Cerra F.B. Hypermetabolism, organ failure and metabolic support. Surgery. 1987; 101 (1): 1–15. PMID: 3541266.

25. Crim M.C., Munro H.N. Protein-energy malnutrition and endocrine function. In: L.J. DeGroot et al. (Eds.), Endocrinology. New York: Grune and Stratton. 1979; 3: 1987.

26. Gogichaishvili S.S. Vliyanie khirurgicheskih metodov lecheniya na central'nuyu i portopechenochnuyu gemodinamiku u bol'nyh portal'noj gipertenziej [Effect of surgical treatment of the central and porto-hepatic hemodynamics in patients with portal hypertension]: authoref. dis. ... cand. med. sci. Moscow, 1990. 28 p. (In Russian)

27. Dem'yanov A.I. Operacionnaya krovopoterya i sravnitel'naya ocenka metodov ee vozmeshcheniya v khirurgii portal'noj gipertenzii [A intraoperative blood loss and a comparative evaluation of methods of reimbursement in surgery of portal hypertension]: authoref. dis. ... cand. med. sci. Moscow, 1987. 22 p. (In Russian)

28. Manuk'yan G.V., Eramishantsev A.K., Musin R.А. Troficheskij gomeokinez i khronicheskaya gepatocellyulyarnaya nedostatochnost' [Trophic homeokinesis and chronic hepatocellular insufficiency]. Proceedings of the VI-th International Congress “Parenteral and Enteral Nutrition”. Moscow, 23–25 October 2002. С. 60–61. (In Russian)

29. Smorodsky А.V. Khirurgicheskoe lechenie oslozhnenij portal'noj gipertenzii u bol'nyh cirrozom s tyazheloj pechenochnoj nedostatochnost'yu [Surgical treatment of complications of portal hypertension in cirrhotic patients with severe hepatic insufficiency]: dis. ... doct. med. sci. Saint-Petersburg, 2010. 172 p. (In Russiаn)

30. Galperin E.I., Semendyaeva M.I., Nekludova E.A. Nedostatochnost’ pecheni [Liver Failure]. Moscow: Medicina, 327 p. (In Russian)

31.

32.

33.