portuli hipertenziis qirurgiuli koreqcia

z. kakabaZe, l. benaSvili, e. beriSvili

(diplomis Semdgomi ganaTlebis Tbilisis saxelmwifo samedicino akademia)

qronikuli hepatitebiTa da RviZlis ciroziT daavadebulTa ricxvis mkveTri zrdis gamo, klinikuri medicinis erT-erT urTules da aqtualur problemas warmoadgens portuli hipertenziis mkurnalobis axali meTodebis SemuSaveba.

letaloba am jgufis pacientebSi ZiriTadad gamowveulia sisxldenebiT kuWisa da saylapavis varikozulad gaganierebuli venebidan da 22%-84%-mde aRwevs (1, 2).

msoflio samedicino literaturaSi dRemde grZeldeba kamaTi portuli hipenrenziis mkurnalobis arsebuli, konservatiuli da qirurgiuli meTodebis efeqturobasa da upiratesobebze.

mkurnalobis iseTi meTodebi, rogoricaa -blokatorebis ineqcia (3,4,5), endoskopiuri skleroTerapia, varikozulad gaganierebuli venebis ligireba (6,7,8), transiugularuli intrahepaturi Sunti (9,10,11) mimarTulia ara TviT mizezis, aramed portuli hipertenziis garTulebaTa likvidaciaze da Sesabamisad ver akmayofilebs klinicistebs. avtorTa umravlesobis azriT yvela zemoT aRniSnuli meTodi efeqturia rogorc sawyisi mkurnaloba, romelic aucileblad unda dasruldes operaciuli CareviT (12,13).

portuli hipertenxiis qirurgiaSi farTod gamoiyeneba sxvadasxva saxis seleqtiuri da araseleqtiuri maSuntirebeli operaciebi (14,15,16,17). avtorTa monacemebiT amgvari operaciebi dakavSirebulia iseT rTul da seriozul garTulebebTan, rogoricaa RviZlis mwvave ukmarisoba da encefalopaTia (18).

portuli sistemis dekompresia sxvadasxva saxis porto-kavaluri anastomozebis saSualebiT iwvevs RviZlisaken mimavali portuli sisxlis perfuziuli wnevis vardnas, rac Tavis mxriv mniSvnelovnad auaresebs isedac daavadebuli RviZlis funqciur mdgomareobas. amasTan erTad RviZlis mier gauvnebelyofili portuli sisxli Tavisuflad gadadis sisxlis sistemur mimoqcevaSi da azianebs centralur nervul sistemas, rac hepatogenuri encefalopaTiis klinikur suraTs iZleva.

yvela zemoT xsenebuli naklovanebebis gaTvaliswinebiT diplomis Semdgomi ganaTlebis Tbilisis saxelmwifo samedicino akademiis organoTa da qsovilTa konservaciisa da transplantaciis laboratoriaSi prof. z. kakabaZis xelmZRvanelobiT SemuSavebul iqna portuli sistemis dekompresiis originaluri meTodi. porto-kavaluri Suntirebis marSruti CarTulia autoorganuli intrakorporaluri biofiltri - hepatizebuli autoelenTa.

masala da meTodebi:

eqsperimentebi Catarebul iqna 20 zrdasrul, ujiSo ZaRlze, sxeulis woniT 18-20 kg. cxovelebi davyaviT 4 eqvivalentur jgufad. yvela jgufis cxovels Tavdapirvelad SeeqmnaT portuli hipertenziis modeli, rezinis gasaberi manJetiT karis venis TandaTanobiTi okluziis saSualebiT.

sxvadasxva saxis maSuntirebeli operaciebis efeqturobis SedarebiTi Sefaseba warmoebul iqna portuli hipertenziis modelirebidan 28-e dRes, rodesac wneva karis sistemaSi aRwevda 280-230 mm-s.

aseptikur pirobebSi, marTvadi endotraqealuri narkozis qveS sruldeboda relaparatomia. rezinis gasaberi manJetis amoRebis Semdeg karis vena ikvanZeboda abreSumis ligaturiT. I da II jgufis cxovelebs (10 ZaRli) CavtardaT mezenteriko-kavaluri da distaluri spleno-renaluri Suntireba Sesabamisad. operaciebi tardeboda mikroqirurgiuli teqnikis gamoyenebiT saoperacio mikroskopis qveS. anastomozebis Sesaqmnelad gamoyenebuli iqna ~ETICON~-is firmis 7/0 merselenis atravmuli sakeravi masala.

portuli wneva sagrZnoblad daqveiTda (10-54 mm.w.s.-mde) mezenterikokavaluri Suntirebis Semdeg.

distaluri spleno-renaluri anastomozis Sesrulebis Semdeg wneva karis sistemaSi Seadgenda 50-95 mm.w.s. portuli wnevis amgvari maCveneblebi SenarCunebuli iqna dakvirvebis periodis bolomde.

amave dros (28 dRe) III jgufis cxovelebSi elenTa gamoyvanil iqna WrilobaSi hepatizaciisaTvis. elenTis sisxlZarRvovan fexze vadebdiT sisxlZarRvovan momWerebs 10 wuTis ganmavlobaSi hepatizaciis dros, hepocitebis migraciis Tavidan asaxileblad. elenTaSi Segvyavda suspenzia, romelic Seicavda RviZlis qsovilis srul ujredul speqtrs. faSvis Rerodan gamomavali elenTis arteriis proqsimaluri da karis venisaken mimavali elenTis venis distaluri boloebi gadaikvanZa da gadaikveTa. elenTis transpoziciisa da marjvena hipoqondrialur midamoSi fiqsaciis Semdeg vudgebodiT sisxlZarRvovani anastomozebis Seqmnas. v.lienalis-i SeerTebuli iqna qveda Rru venasTan, xolo ....-i daukavSireT karis venas ~bolo gverdSi~ tipis anastomozebis saSualebiT?.

operaciis dasrulebisTanave wneva karis venaSi Seadgenda 120-170 mm. wylis sv. da SenarCunebuli iqna dakvirvebis periodis bolomde.

cxovelebze dakvirvebis maqsimalur periods Seadgenda 6 Tve.

Cvens mier warmoebuli dekompresiuli porto-kavaluri Suntebis funqcionaluri aqtivobisa da portuli sisxlis intrakorporaluri autoorganuli biofiltris efeqturobis Sefasebas vawarmoebdiT cxovelebis saerTo mdgomareobaze dakvirvebisa da sxvadasxva funqcionaluri, bioqimiuri da sxva testebis dinamikuri kontrolis safuZvelze. Tavis tvinis bioeleqtruli aqtivoba registrirebul iqna eleqtroencefalografze “EEG-lox”(ungreTi).

Sedegebi:

yvelaze aradamakmayofilebeli Sedegebi aRiniSneboda I jgufis cxovelebSi. cxovelebis 80% daiRupa uaxloes postoperaciul periodSi, encefalopaTiisa da RviZlis mwvave ukmarisobis gamo. periferiuli sisxlis bioqimiurma analizma gamoavlina hipoalbuminemia da hiperamonemia. eeg-ze aRiniSneboda encelopaTiis niSnebi, autofsiaze arcerTi mezenterikokavalur anastomozi ar aRmoCnda embolizirebuli.

II jgufis cxovelebSi portuli sistemis dekompresiis Sedegad daiRupa 2 cxoveli 28-40 dRis encefalopaTiisa da RviZlis mwvave ukmarisobis gamo. danarCeni cxovelebi imyofebodnen dakvirvebis qveS 6 Tvis ganmavlobaSi.

periferiuli sisxlis bioqimiurma analizma gamoavlina hipoalbuminemia da hiperamonemia.

RviZlis qsovilis histologiurma gamokvlevebma gviCvena misi struqturis rRveva diskompleqsaciisa da RviZlis normaluri struqturis ararsebobis gamo. gamovlenil iqna hepatocitebis difuziuri steatozi. atrofirebuli RviZlis qsovili aRiniSneboda glisonis kafsulis maxloblad. RviZlis parenqimis amgvar cvlilebebs Tan ar axlavda SemaerTebeli qsovilis hiper da atipiuri ganviTareba. gamonakliss warmoadgenda centraluri venebis kedlebis gasteleba.

cxovelebis III jgufSi daiRupa 2 ZaRli, encelopaTiisa da RviZlis mwvave ukmarisobis gamo.

periferiuli sisxlis bioqimiuri analizis Sedegad miRebuli maCveneblebi warmodgenilia tabulaSi.

eeg-ze aRiniSneboda paTologiuri cvlilebebis involucia, romelic mkafiod gamoixateboda portuli hipertenziis modelirebis pirobebSi. eeg-s suraTi ar gansxvavdeboda normisagan mesame kviris dasasruls. pirdapirma intraoperaciulma portografiam gamoavlina kontrastuli nivTierebis Tavisufali pasaJi qveda Rru venis sistemaSi.

hepatizebuli elenTis morfologiurma gamokvlevam naTelyo hepatocitebis difuziuri ganlageba elenTis parenqimaSi pirveli 3-5 dRis ganmavlobaSi. ujredebis citoplazma bazofiluri, kargad gamoxatuli birTviT. 25-30 dRis Semdeg hepatocitebi qmnian RviZlis kompaqtur organotipiur struqturas. arc erT SemTxvevaSi ar dafiqsirebula naRvlis sadinrebis ganviTareba. implantirebuli hepatocitebis sicocxlisunarianoba SenarCunebuli iyo cxovelebze dakvirvebis mTeli periodis ganmavlobaSi. citoqimiuri gamokvlevebis saSualebiT gamovlenil iqna, rom hepatizebuli elenTa asrulebs RviZlis iseT specifiur funqciebs, rogoricaa glukoneogenezi, albuminis sinTezi da sxva. RviZlis qsovilis histologiurma gamokvlevebma gviCvena centraluri venebis gafarToeba da maTi kedlebis gasqeleba. RviZlis parenqimaSi ar iqna aRmoCenili aranairi atrofiuli cvlileba. dises sivrceebi gafarToebuli iyo yvela SemTxvevaSi. hepatocitebs gaaCndaT normaluri zoma, aRiniSneboda regeneraciis zonebi. RviZlis morfologiuri struqturis normalizacias Tan axlda cxovelTa saerTo mdgomareobisa da bioqimiuri maCveneblebis gaumjobeseba.

daskvna:

Cvens mier Catarebuli eqsperimentalur-kuleviTi Sromis safuZvelze SeiZleba davaskvnaT, rom portuli sisxlis intrakorporalur autorganul biofiltrs gaaCnia rigi upiratesobani. pirvel rigSi aRsaniSnavia, rom heptizebuli autoelenTis CarTva porto-kavaluri Suntirebis marSrutSi saSualebas gvaZlevs SevinarCunoT RviZlisaken mimavali portuli sisxlis perfuziuli wneva, rac Tavis mxriv xels uwyobs RviZlSi mimdinare paTologiuri procesebis involucias. meores mxriv hepatizebuli elenTa asrulebs detoqsikaciur funqcias da masSi gamavali portuli sisxlis moxvedra qveda Rru venis sistemaSi ar iwvevs encefalopaTias. aqve unda aRiniSnos, rom hepatizebuli elenTa asrulebs RviZlis iseT specifiur funqciebs, rogoricaa glukogenezi, albuminis sinTezi da sxva.

maCveneblebi me-12-14 dRes operaciis Semdeg me-5-6 dRes operaciis Semdeg 1,5-2 Tves operaciis Semdeg 5-6 Tves operaciis Semdeg

amiaki (mg%) 0.30 0.36 0.30 0.35

Sardovana (g/1) 0.30 0.36 0.28 0.40

saerTo bilirubini (mkmd/1) 5.47 5.0 5.0 6.0

sawerTo cila (g/1) 76.3 73.2 70.1 67.9

saerTo qolesterini (mmd/1) 5.2 4.92 5.42 4.61

glukoza (mmol/1) 5.1 4.8 4.6 4.9

Aa s t 0.29 0.19 0.22 0.6-0.8

a l tA 0.58 0.52 0.50 0.7-0.9

a/g koeficienti 1.2 0.93 1.02 1.2

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