{"id":820,"date":"2013-03-14T09:41:09","date_gmt":"2013-03-14T09:41:09","guid":{"rendered":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/?page_id=820"},"modified":"2013-06-10T17:00:56","modified_gmt":"2013-06-10T17:00:56","slug":"15-2","status":"publish","type":"page","link":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/?page_id=820","title":{"rendered":"15 J\u00edcnov\u00e9 varixy a port\u00e1ln\u00ed hypertenze"},"content":{"rendered":"

\u00davodem<\/h3>\n

Port\u00e1ln\u00ed hypertenze znamen\u00e1 zv\u00fd\u0161en\u00ed tlaku v port\u00e1ln\u00edm \u0159e\u010di\u0161ti, jeho\u017e p\u0159\u00ed\u010dinou je zt\u00ed\u017een\u00ed pr\u016ftoku port\u00e1ln\u00ed krve p\u0159ed j\u00e1try (tromb\u00f3za port\u00e1ln\u00ed v\u00e9ny), v j\u00e1trech (nej\u010dast\u011bji cirh\u00f3za) nebo za j\u00e1try (uz\u00e1v\u011br hepat\u00e1ln\u00edch \u017eil). Podle toho se rozli\u0161uje port\u00e1ln\u00ed hypertenze prehepat\u00e1ln\u00ed, hepat\u00e1ln\u00ed a posthepat\u00e1ln\u00ed. Zv\u00fd\u0161en\u00fd tlak v port\u00e1ln\u00edm \u0159e\u010di\u0161ti vede postupn\u011b k rozvoji portosystemick\u00fdch kolater\u00e1l, z nich\u017e nejd\u016fle\u017eit\u011bj\u0161\u00ed jsou varixy j\u00edcnu a \u017ealudku s mo\u017en\u00fdm vznikem krv\u00e1cen\u00ed z varix\u016f. U dosp\u011bl\u00fdch je nej\u010dast\u011bj\u0161\u00ed p\u0159\u00ed\u010dinou port\u00e1ln\u00ed hypertenze jatern\u00ed cirh\u00f3za, u d\u011bt\u00ed pak prehepat\u00e1ln\u00ed uz\u00e1v\u011br porty v d\u016fsledku prob\u011bhl\u00e9 omfalitidy v novorozeneck\u00e9m v\u011bku.<\/p>\n

Chirurg p\u0159ich\u00e1zel do styku s touto problematikou p\u0159ev\u00e1\u017en\u011b p\u0159i \u0159e\u0161en\u00ed krv\u00e1cen\u00ed z j\u00edcnov\u00fdch varix\u016f, co\u017e p\u0159edstavuje jen v\u00fdsek t\u00e9to velmi \u0161irok\u00e9 problematiky. Rozvoj endoskopie (stav\u011bn\u00ed krv\u00e1cen\u00ed) a interven\u010dn\u00ed radiologie (transjugul\u00e1rn\u00ed intrahepat\u00e1ln\u00ed portosyst\u00e9mov\u00e1 spojka \u2013 TIPS) vedl k tomu, \u017ee se tyto metody dnes staly u velk\u00e9 v\u011bt\u0161iny nemocn\u00fdch m\u00e9n\u011b invazivn\u00ed alternativou chirurgick\u00e9 l\u00e9\u010dby [1, 2]. L\u00e9\u010dba port\u00e1ln\u00ed hypertenze a j\u00edcnov\u00fdch varix\u016f dnes p\u0159edstavuje rozs\u00e1hlou interdisciplin\u00e1rn\u00ed problematiku, kter\u00e9 je v\u011bnov\u00e1na cel\u00e1 \u0159ada samostatn\u00fdch prac\u00ed a monografi\u00ed [3, 4, 5, 6]. Na\u0161\u00edm c\u00edlem je zde v prvn\u00ed \u010d\u00e1sti t\u00e9to kapitoly pouk\u00e1zat na p\u0159\u00ednos chirurgie k t\u00e9to problematice v minulosti z pohledu olomouck\u00fdch zku\u0161enost\u00ed. I kdy\u017e bli\u017e\u0161\u00ed komplexn\u00ed pojedn\u00e1n\u00ed o t\u00e9to problematice p\u0159esahuje mo\u017enosti t\u00e9to publikace, ve druh\u00e9 \u010d\u00e1sti t\u00e9to kapitoly je pojedn\u00e1no p\u0159edstavitelem sou\u010dasn\u00e9 generace olomouck\u00fdch chirurg\u016f, kter\u00fd se touto problematikou zab\u00fdv\u00e1, o st\u00e1le je\u0161t\u011b existuj\u00edc\u00edch, i kdy\u017e \u0159\u00eddk\u00fdch p\u0159\u00edpadech, kdy se chirurgie do \u0159e\u0161en\u00ed t\u00e9to problematiky m\u016f\u017ee zapojit.<\/p>\n

Literatura<\/h3>\n
    \n
  1. Krajina A, Peregrin JH, et al. Interven\u010dn\u00ed radiologie. Miniinvazivn\u00ed terapie. 1. vyd\u00e1n\u00ed. Hradec Kr\u00e1lov\u00e9: Vydala Olga \u010cerm\u00e1kov\u00e1; 2005.<\/li>\n
  2. Zavoral M, D\u00edt\u011b P, \u0160pi\u010d\u00e1k J, Bure\u0161 J, et al. Nov\u00e9 trendy v digestivn\u00ed endoskopick\u00e9 diagnostice a l\u00e9\u010db\u011b. Praha: Grada Publishing; 2000.<\/li>\n
  3. Berchtold R. Das Syndrom des Pfortaderhochdrucks. Bern Stuttgart Wien: Verlag Hans Hubert; 1970.<\/li>\n
  4. Bala\u0161 V. Chirurgick\u00e9 \u0159e\u0161en\u00ed port\u00e1ln\u00ed hypertenze. Praha: Avicenum; 1986.<\/li>\n
  5. Bosch J, Groszmann RJ, editors. Portal Hypertension. Pathophysiology and Treatment. Oxford: Oxford Blackwell Scietific Publications; 1994.<\/li>\n
  6. Lata J, D\u00edt\u011b P, H\u016flek P, Krajina A, Kr\u00e1l V, \u0160tafa V. Port\u00e1ln\u00ed hypertenze p\u0159i jatern\u00ed cirh\u00f3ze a jej\u00ed d\u016fsledky. Plze\u0148: GAAN CZ; 2000.<\/li>\n<\/ol>\n

    15.1 Bibliografie olomouck\u00fdch prac\u00ed o varixech j\u00edcnu a port\u00e1ln\u00ed hypertenzi<\/h3>\n

    Chirurgie port\u00e1ln\u00ed hypertenze st\u00e1la od po\u010d\u00e1tku p\u016fsoben\u00ed prof. Rapanta v Olomouci v pop\u0159ed\u00ed jeho z\u00e1jmu. Prof. MUDr. Dagmar Hauftov\u00e1, CSc. (nar. 2. 6. 1927, zem\u0159ela 2011), p\u0159edn\u00ed \u010desk\u00e1 hepatolo\u017eka, dlouholet\u00e1 pracovnice I. intern\u00ed kliniky v Olomouci, vzpom\u00edn\u00e1 (citov\u00e1no z: Hauftov\u00e1, D., v knize: Duda, M., a kolektiv. Historie chirurgie, vybran\u00e9 stat\u011b olomouck\u00e9 a moravsk\u00e9 chirurgie. Vydala Univerzita Palack\u00e9ho v Olomouci, 1. vyd\u00e1n\u00ed 2008, 2. vyd\u00e1n\u00ed 2009) na spolupr\u00e1ci s prof. Rapantem takto:<\/p>\n

    \"Obr.<\/a>

    Obr. 1
    Setk\u00e1n\u00ed s prof. Skinnerem a jeho man\u017eelkou p\u0159i porcov\u00e1n\u00ed krocana na jeho farm\u011b u Michigansk\u00e9ho jezera na Den d\u00edk\u016fvzd\u00e1n\u00ed (Thanksgiving Day) po\u010d\u00e1tkem 90. let minul\u00e9ho stolet\u00ed<\/p><\/div>\n

    \u201eProto\u017ee mi byla na intern\u011b sv\u011b\u0159ena hepatologie, poznala jsem pana profesora i trochu bl\u00ed\u017ee. Byl obezn\u00e1men s pracemi slavn\u00fdch americk\u00fdch chirurg\u016f, nap\u0159. Warrena. Jako prvn\u00ed ve st\u00e1t\u011b zav\u00e1d\u011bl portokav\u00e1ln\u00ed spojky u port\u00e1ln\u00ed hypertenze do l\u00e9\u010debn\u00e9 praxe. Jsem mu vd\u011b\u010dn\u00e1 za to, \u017ee jsem poznala na chirurgii \u0159adu chorob s hepatologickou problematikou, kter\u00e9 bych jinak nevid\u011bla nebo v takov\u00e9 m\u00ed\u0159e (nap\u0159. r\u016fzn\u00e1 stadia jatern\u00edch cirh\u00f3z, prehepatick\u00e9 port\u00e1ln\u00ed hypertenze, kongenit\u00e1ln\u00ed fibr\u00f3zy jater s port\u00e1ln\u00ed hypertenz\u00ed a dal\u0161\u00ed). Tito nemocn\u00ed se zde toti\u017e koncentrovali ze \u0161irok\u00e9ho okol\u00ed, v\u010detn\u011b Slovenska, a m\u011bla jsem zde mo\u017enost vid\u011bt i dal\u0161\u00ed m\u00e9n\u011b \u010dast\u00e9 p\u0159\u00edznaky jatern\u00edch chorob, nap\u0159. ascites pankreatick\u00e9ho p\u016fvodu s obsahem vysok\u00fdch hodnot amyl\u00e1z, diferenci\u00e1ln\u00ed diagnostiku chylozn\u00edho ascitu, intrahepatick\u00e9 cholest\u00e1zy r\u016fzn\u00e9 etiologie apod. Byla jsem p\u0159\u00edtomna, kdy\u017e pan profesor jako prvn\u00ed ve st\u00e1t\u011b prov\u00e1d\u011bl na rtg transhepatickou cholangiografii a poda\u0159ilo se mu rychle nabodnout \u017elu\u010dov\u00e9 cesty, kter\u00e9 nebyly dilatovan\u00e9. Je\u0161t\u011b dnes mi mraz\u00ed v z\u00e1dech. Byla jsem tak\u00e9 p\u0159\u00edtomna, jak na s\u00e1le prov\u00e1d\u011bl portokav\u00e1ln\u00ed anastom\u00f3zy. I jako chirurgick\u00fd laik jsem vid\u011bla, jak se \u0161etrn\u011b choval ke tk\u00e1n\u00edm a org\u00e1n\u016fm. \u017div\u011b vzpom\u00edn\u00e1m na p\u0159\u00edpad nemocn\u00e9ho s prehepatickou port\u00e1ln\u00ed hypertenz\u00ed, u kter\u00e9ho \u0161irok\u00e1 kolater\u00e1la prob\u00edhala v kontaktu s pankreatem. Preparaci \u017e\u00edly prov\u00e1d\u011bl pan profesor s takovou ohleduplnost\u00ed, \u017ee i mn\u011b, internistovi, to vyr\u00e1\u017eelo dech a sou\u010dasn\u011b vzbuzovalo i hlubok\u00fd obdiv. Jednou tak\u00e9 cht\u011bl zkusit l\u00e9\u010dit port\u00e1ln\u00ed hypertenzi s krv\u00e1cen\u00edm podvazem arterie hepatica. Operace byla prov\u00e1d\u011bna experiment\u00e1ln\u011b na psech, kter\u00fdm po operaci byla pod\u00e1v\u00e1na antibiotika a psi p\u0159e\u017e\u00edvali. Prostudovala jsem literaturu k t\u00e9to problematice a tak\u00e9 variabilitu anatomick\u00e9ho v\u011btven\u00ed jatern\u00ed tepny u \u010dlov\u011bka a dosp\u011bla jsem k n\u00e1zoru, \u017ee by to bylo riskantn\u00ed, \u017ee by nemocn\u00fd mohl zem\u0159\u00edt na nekr\u00f3zu jater. Zobrazovac\u00ed metody arterie hepaticae nebyly na v\u00fd\u0161i\u2026<\/p>\n

    Dodala jsem si odvahu a za\u0161la za panem profesorem a v jeho pracovn\u011b mu vyjevila moje obavy. Pan profesor od operace upustil a m\u016fj obdiv a \u00facta k n\u011bmu vzrostly. Tak\u00e9 jsem s n\u00edm spolupracovala na v\u011bdeck\u00e9 pr\u00e1ci o zku\u0161enostech chirurgick\u00e9ho l\u00e9\u010den\u00ed port\u00e1ln\u00ed hypertenze z hlediska indikace a ev. kontraindikace intern\u00edho r\u00e1zu. Pan profesor mi dal kl\u00ed\u010de od sv\u00e9 pracovny, kam se p\u0159enesly chorobopisy v\u0161ech nemocn\u00fdch a ve ve\u010dern\u00edch hodin\u00e1ch jsem zde pracovala. Jeho d\u016fv\u011bra m\u011b ohromila. V\u017edy\u0165 jsem byla nezku\u0161en\u00fdm sekund\u00e1\u0159em p\u00e1r rok\u016f po promoci. Vd\u011b\u010d\u00edm mu za to, \u017ee tak z\u00e1sadn\u011b p\u0159isp\u011bl k m\u00e9 hepatologick\u00e9 v\u00fdchov\u011b.<\/p>\n

    Pan profesor m\u011bl tak\u00e9 hlubok\u00fd vztah k nemocn\u00fdm t\u00edm, \u017ee jim slou\u017eil, a\u0165 to byl p\u00e1n nebo kr\u00e1l. Dotklo se m\u011b, kdy\u017e nep\u0159\u00edli\u0161 d\u00e1vno na v\u011bdeck\u00e9 rad\u011b obhajoval chirurg z Brna svoji kandid\u00e1tskou pr\u00e1ci o sklerotizaci j\u00edcnov\u00fdch varix\u016f u port\u00e1ln\u00ed hypertenze. St\u00e1le jsem \u010dekala, \u017ee se o prof. Rapantovi alespo\u0148 zm\u00edn\u00ed. Ale kdepak. Mlad\u00e9 nezaj\u00edm\u00e1, jak\u00e9 stavebn\u00ed kameny klinik stav\u011bli sta\u0159\u00ed, na kter\u00fdch vyrostla cel\u00e1 \u0161kola. O chirurgii port\u00e1ln\u00ed hypertenze se v Olomouci v\u011bd\u011blo d\u0159\u00edve ne\u017e v Praze a v Brn\u011b.<\/p>\n

    Vznikla zde chirurgick\u00e1 \u0161kola a jeho \u017e\u00e1ci a n\u00e1sledn\u00edci pokra\u010dovali v zapo\u010dat\u00e9m d\u00edle sv\u00e9ho u\u010ditele a\u017e do sou\u010dasnosti.\u201c 70. l\u00e9ta minul\u00e9ho stolet\u00ed byla obdob\u00edm, kdy se chirurgie je\u0161t\u011b uplat\u0148ovala ve v\u011bt\u0161\u00ed m\u00ed\u0159e p\u0159i krv\u00e1cen\u00ed z j\u00edcnov\u00fdch varix\u016f. P\u0159\u00edm\u00e9 v\u00fdkony na j\u00edcnu prod\u011blaly sv\u016fj v\u00fdvoj a po\u010d\u00e1tkem 70. let byla v Olomouci hojn\u011b u\u017e\u00edv\u00e1na metoda podle americk\u00e9ho chirurga Skinnera. P\u0159es obt\u00ed\u017ee spojen\u00e9 v t\u00e9 dob\u011b s mo\u017enost\u00ed zahrani\u010dn\u00edch styk\u016f, se poda\u0159ilo nav\u00e1zat odborn\u00e9 i p\u0159\u00e1telsk\u00e9 kontakty s t\u00edmto v\u00fdznamn\u00fdm americk\u00fdm j\u00edcnov\u00fdm chirurgem (obr. 1). Na obr. 2a\u2013e jsou zobrazeny n\u011bkter\u00e9 dnes ji\u017e historick\u00e9 operace p\u0159\u00edm\u00fdch v\u00fdkon\u016f p\u0159i krv\u00e1cen\u00ed z j\u00edcnov\u00fdch varix\u016f (P\u0159evzato z pr\u00e1ce: \u0160er\u00fd Z, Duda M, Fischer J, Dlouh\u00fd M. Bleeding from oesophageal varices. Acta Univ Olomouc, Fac Med. 1974;71:53\u201367).<\/p>\n

    D\u00e1le uv\u00e1d\u00edme chronologick\u00fd v\u00fd\u010det publikac\u00ed zam\u011b\u0159en\u00fdch jak na p\u0159\u00edm\u00e9 v\u00fdkony na j\u00edcnu, tak na problematiku port\u00e1ln\u00ed hypertenze v\u016fbec.<\/p>\n\n\n\n\n\n
    \n

    \"Obr.<\/a>

    Obr. 2a
    Sch\u00e9mata n\u011bkter\u00fdch dnes ji\u017e historick\u00fdch p\u0159\u00edm\u00fdch v\u00fdkon\u016f p\u0159i krv\u00e1cen\u00ed z j\u00edcnov\u00fdch varix\u016f:
    Transtorak\u00e1ln\u00ed vta\u017een\u00ed \u017ealudku nad br\u00e1nici a gastrotomie t\u011bsn\u011b pod kardii<\/p><\/div><\/td>\n

    		\n

    \"Obr.<\/a>

    Obr. 2b:
    Sch\u00e9mata n\u011bkter\u00fdch dnes ji\u017e historick\u00fdch p\u0159\u00edm\u00fdch v\u00fdkon\u016f p\u0159i krv\u00e1cen\u00ed z j\u00edcnov\u00fdch varix\u016f:
    P\u0159es gastrotomii zachycen\u00ed ezofagogastrick\u00e9ho p\u0159echodu z\u00e1v\u011bsn\u00fdmi stehy<\/p><\/div><\/td>\n<\/tr>\n

    \n

    \"Obr.<\/a>

    Obr. 2c:
    Sch\u00e9mata n\u011bkter\u00fdch dnes ji\u017e historick\u00fdch p\u0159\u00edm\u00fdch v\u00fdkon\u016f p\u0159i krv\u00e1cen\u00ed z j\u00edcnov\u00fdch varix\u016f:
    Pro\u0161it\u00ed ezofagogastrick\u00e9ho p\u0159echodu a varik\u00f3zn\u00edho uzlu pokra\u010duj\u00edc\u00edm stehem<\/p><\/div><\/td>\n

    		\n

    \"Obr.<\/a>

    Obr. 2d:
    Sch\u00e9mata n\u011bkter\u00fdch dnes ji\u017e historick\u00fdch p\u0159\u00edm\u00fdch v\u00fdkon\u016f p\u0159i krv\u00e1cen\u00ed z j\u00edcnov\u00fdch varix\u016f:
    Opichy a pro\u0161it\u00ed varix\u016f ze zevn\u011bj\u0161ka p\u0159es st\u011bnu j\u00edcnu, po otev\u0159en\u00ed lumen a bez otev\u0159en\u00ed j\u00edcnu jen po vypreparov\u00e1n\u00ed slizni\u010dn\u00edho v\u00e1lce<\/p><\/div><\/td>\n<\/tr>\n

    \n

    \"Obr.<\/a>

    Obr. 2e:
    Sch\u00e9mata n\u011bkter\u00fdch dnes ji\u017e historick\u00fdch p\u0159\u00edm\u00fdch v\u00fdkon\u016f p\u0159i krv\u00e1cen\u00ed z j\u00edcnov\u00fdch varix\u016f:
    Resekce nebo transsekce vypreparovan\u00e9ho slizni\u010dn\u00edho v\u00e1lce<\/p><\/div><\/td>\n

    		<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

    .<\/span><\/p>\n

    1962<\/h6>\n