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