限制性门腔静脉侧侧分流加肝动脉强化灌注术治疗门静脉高压症

目的探讨限制性门腔静脉侧侧分流（附加限制环）、肝动脉强化灌注术在门脉高压症治疗中的应用。方法门脉高压症合并食管胃底静脉曲张出血（静止期）病人31例,均择期行限制性门腔静脉侧侧分流（附加限制环）、肝动脉强化灌注术、脾切除术。结果再次出现上消化道出血率8％（2／25）,肝性脑病的发生率8％（2／25）;术后复查上消化道造影,食管胃底静脉曲张消失或好转92％;经腹部超声检查示门腔静脉吻合口通畅,无血栓形成;血常规检查,白细胞、血色素及血小板基本恢复正常,肝功能及全身营养状况均明显好转。结论此术式术后门静脉压力降压满意,手术死亡率低,食管胃底静脉曲张好转,消失率、再出血率及腹水消失率均优于其他术式,而术后脑病的发生率低于其他分流术,为一种治疗门脉高压上消化道出血好的治疗措施。     

金属环在分流术治疗门静脉高压症中的应用

限制性门腔静脉侧侧分流术治疗门脉高压症,虽已较为广泛应用,且疗效较满意,但吻合口处不添加限制措施,术后吻合口将出现扩大,难以达到真正的限制目的。我们自1989年11月开始,对20例实施治疗性限制性分流术的患者,在其吻合口处均放置了一个8mm～11mm 的金属限制环,疗效满意。作者就本限制环的限制作用、手术操作方法及适应证进行了探讨。     

限制性门腔静脉侧侧分流术及脾移植术治疗门脉高压症9例

自1986年1月～1990年4月我院先后为9例门脉高压症合并上消化道出血的病人,施行了限制性门静脉和下腔静脉则侧分流术(以下简称门腔静脉侧侧分流术)。经过3年6个月的随访观察,疗效满意,现报告如下。     

改良Sugiura手术联合脾腔分流术治疗门静脉高压症

目的评估改良Sugiura手术联合限制性脾腔静脉分流术治疗门静脉高压症食管胃底曲张静脉破裂出血的疗效。方法对行改良sugiura手术联合限制性脾腔静脉分流术治疗的30例门静脉高压症患者的临床资料进行回顾性分析。结果术后自由门静脉(FPP)较术前平均下降(9.98±7.33)cm H2O(P<0.01),门静脉直径(PVD)由术前明显增粗(1.6±0.18)cm H2O逐渐恢复正常(1.4±0.14)cm H2O。门静脉最大血流速度(PVm ax)及血流量(PVF)明显降低。间置人造血管通畅,无明显血栓形成。本组30例无手术死亡和近期再出血。结论改良Sugiura手术联合人造血管间置限制性脾腔静脉分流术止血效果确切,可以使分流、断流术止血方面的优点相加,同时有效地防治了门静脉高压性胃病,并减少了肝性脑病的发生,而手术的难度和风险并未增加,因此不失为目前门脉高压症外科治疗的理想术式。     

门腔分流附加肝脏动脉化手术治疗门静脉高压症的疗效观察

目的:门腔分流治疗门静脉高压,是降低门静脉压力、防止再出血以及消除腹水的有效方法。但门腔分流术后由于肝脏血流灌注减少,术后脑病发生率较高。因此,在门腔分流的同时附加肝脏动脉化手术来增加肝脏的血流灌注,进而改善肝功能,降低脑病以及腹水的发生率。方法:1983年以来对12例门脉高压合并上消化道出血患者行门脉分流附加肝动脉化手术,经过1 a～10 a随访观察疗效满意。结果:11例患者术后肝功能恢复正常,无再出血,无脑病,无腹水发生,均参加正常工作。本组仅1例出现轻度脑病,经治疗及限制蛋白饮食后恢复正常。结论:门腔分流能有效地降低门静脉压力,动脉化后肝血流量增加,可显著改善肝功能,减轻肝脏纤维化,本组术后无再出血,无腹水,基本上无脑病的发生。     

门脉高压手术治疗的进展

门脉系统分流术在临床广泛应用已30余年,对治疗门脉高压症合并上消化道出血有较好的效果。门-腔静脉分流术和脾-肾静脉分流术对降低门脉压力虽较明显、控制出血较好,但术后常出现不同程度的肝功能损伤。肝功能衰竭是术后致死的主要原因,几乎占死亡病例的2/3。     

肝硬变门静脉高压症病人门静脉-腔静脉分流术前后生长激素水平的动态观察

为研究肝硬变门静脉高压症患者门静脉-腔静脉分流术前后生长激素水平变化,作者应用放射免疫分析方法测定了22例肝硬变门静脉高压症患者行门静脉-腔静脉分流术和16例无肝脏和肾脏疾病的对照组患者行胃肠道肿瘤切除手术前后门静脉、外周静脉和动脉血浆中GH水平结果,发现肝硬变组术前、术中、术后3天,术后7天的门静脉、周围静脉和动脉血浆中GH水平都明显高于对照组(P<0.01),肝硬变组术前、术中和术后动脉、周围静脉和门静脉的差异无显著性(P>0.05)。肝硬变组门静脉血中GH水平与门静脉压力无明显相关性(r=0.02,P>0.05)。肝硬变门静脉高压症患者血中GH明显增高。行门静脉-腔静脉分流术后GH水平无明显变化。     

肠系膜上静脉下腔静脉侧侧吻合术治疗门静脉高压症

门静脉高压症并发食管静脉曲张出血的死亡率高达50～75％。目前多数认为择期施行门体分流术仍为较适宜的治疗方法;采用的术式很多,各有其利弊。尽管如比,Stipa氏等仍认为以warren的选择性区域性分流术、AdamSon的门腔端侧分流后加门静脉末稍动脉化的手术以及LOrd的肠系膜上静脉下腔静脉侧侧分流术这三种手术比较值得重视。关于肠系膜上静脉直接与下腔静脉进行侧侧吻合的分流术尚无专题介绍,今将我院施行的肠系膜上静脉下腔静脉侧侧吻合术获得成功的一例报导如下并提出初步体会:     

附加金属环限制的门腔静脉侧侧分流加断流术治疗门静脉高压症

目的：总结附加金属环限制的门腔静脉侧侧分流加断流术治疗门静脉高压曲张静脉出血的效果。方法：对实施本联术式的门静脉高压症62例作回顾性分析。结果：术后1个月内死亡1例,手术病死率1．6％;术后近期无1例再出血,再出血率3．4％,术后肝性脑病发生率3．4％,腹水消失率96．6％。结论：本术式是治疗门静脉高压症合理、实用的一种术式。     

肝硬变门静脉高压症患者门腔静脉分流术前后血中胰高血糖素水平变化的观察

目的方法:应用放射免疫分析方法,测定了16例肝硬变门静脉高压症患者行门腔静脉分流术和16例无肝脏和胰腺疾病的对照组患者行胃肠道肿瘤切除术手术前后门静脉、外周静脉和动脉血浆中胰高血糠素(Glc)水平。结果:肝硬变组术前、术中、术后3天、术后7天的门静脉、周围静脉和动脉血浆中Glc水平都明显高于对照组(P<0.01);肝硬变组术后3天及7天动脉、周围静脉和门静脉Glc水平比术前和术中均明显降低(P<0.01);肝硬变组术前和术中无显著性差异(P>0.05);肝硬变组术后3天和7天差异无显著性(P>0.05)。硬变组门静脉血中Glc水平与门静脉压力呈明显正相关(r=0.57,P>0.001)。结论:肝硬变门静脉高压症患者的Glc血症可能是因为胰腺及胃肠道产生Glc增加和肝脏代谢Glc能力降低所致;门腔静脉分流术后肝硬变门静脉高压症患者Glc水平明显降低。     

Modulation of TCDD-induced wasting syndrome by portocaval anastomosis and vagotomy in Long-Evans and Han/Wistar rats

Portocaval anastomosis and vagotomy operations were performed in Long-Evans (L-E) and Han/Wistar (H/W) rats to elucidate the mechanism of anorexia induced by TCDD (2,3,7,8-tetrachlorodibenzo-p-dioxin). TCDD-sensitive L-E rats were given a sublethal (5 μg/kg) or a lethal dose (20 μg/kg) by gavage 5–8 weeks after portocaval anastomosis. TCDD-resistant H/W rats were given a nonlethal dose (500 or 7200 μg/kg). The shunt operation did not reduce lethality from TCDD. The effect on wasting of the marginally toxic dose of 5 μg/kg in L-E rats was potentiated by the portocaval operation, and the lethal dose was effective in both shunted and sham-operated L-E rats. TCDD failed to decrease food intake and body weight in shunted rats of H/W strain at either dose level though it did so in sham-oprated controls. The lack of effect may be due to the already reduced weight of shunted rats at the time of TCDD dosing. TCDD anorexia was not explained by changes in histamine or serotonin (5-HT) turnover in the brain. Vagotomy did not influence lethality after TCDD, although reduction in food intake was somewhat blunted in H/W rats. The results seem to indicate that the anorectic effect of TCDD is modified when portal blood bypasses the liver. The mechanisms remain to be elucidated in detail, but the results do not favor the role of liver as the only or the major initiator of TCDD anorexia. Little evidence was found to support a crucial role of vagal afferent input.     

断流术与分流术在门静脉高压治疗的比较

目的探讨分流术与脾切除及贲门周围血管离断术对门静脉高压症的治疗作用。方法回顾该院从2005年6月至2012年6月共113例采用脾切除及贲门周围血管离断术与分流术治疗门脉高压症患者的临床资料,分析手术前后患者脾功能亢进症状、肝功能、食管胃底静脉曲张等情况,比较两者的手术死亡率及术后再出血、肝性脑病和门静脉血栓的发生率。结果治疗后两组患者自由门静脉压(free portal pressure,FPP)均明显低于治疗前,治疗前后比较差异有统计学意义(P0.05),两组患者治疗后FPP差异无显著性,无统计学意义(P0.05);治疗后及随访期间,分流组分流术组术后食管胃底静脉曲张减轻率和腹水消失率优于断流组,差异有统计学意义(P0.05),近期肝功能好转情况两组间差异无统计学意义(P0.05);术后随访患者,分析两组患者术后再出血、肝性脑病和门静脉血栓的发生率,分流组再出血及门静脉血栓发生率低于断流组,两者差异有统计学意义(P0.05);断流组肝性脑病发生率显著低于分流组,两者差异有统计学意义(P0.01)。结论对于门静脉高压症患者,脾切除及贲门周围血管离断术相比分流术具有更好的治疗效果,该手术方法具有肝性脑病不易发生,较好的维持入肝血流且止血彻底,肝功能影响小的优势,且手术创伤较小、手术死亡率低、操作简便,易于在基层推广。     

A comparison between gastric and oesophageal variceal haemorrhage treated with transjugular intrahepatic portosystemic stent shunt (TIPSS)

Background : Transjugular intrahepatic portosystemic stent-shunts (TIPSS) are becoming widely used in the management of oesophageal variceal haemorrhage (OVH). Their place in the treatment of gastric variceal haemorrhage (GVH), a condition with a traditionally poor prognosis, remains unclear. The aims of our study were to compare portal haemodynamics and patient outcome in patients undergoing TIPSS for either GVH or OVH.
Patients and Methods : 106 consecutive patients undergoing TIPSS at our institution for either GVH (32 patients) or OVH (74 patients) were studied. The groups were similar with regard to patient age, aetiology and severity of liver disease and number of procedures carried out as an emergency (34.4% vs. 36.5%). Episodes of shunt insufficiency, rebleeding, encephalopathy and other clinical sequela were recorded. Mean follow-up was similar in both patient groups (14.2 vs. 12.1 months).
Results : Baseline portocaval pressure gradient was lower in patients with GVH compared with those with OVH (13.0±0.9 mmHg vs. 19.0±0.6 mmHg) ( P < 0.001). Rates of variceal rebleeding, encephalopathy and shunt insufficiency during follow-up were similar in both groups and there was no difference in survival.
Conclusion : Patients with GVH had markedly lower portocaval pressure gradients than those with OVH, but shunt and clinical complications and survival were similar during follow-up. TIPSS appears to be an effective treatment for GVH and should be compared with endoscopic or surgical techniques in controlled trials.     

The aryl hydrocarbon receptor is required for developmental closure of the ductus venosus in the neonatal mouse

A developmental role for the Ahr locus has been indicated by the observation that mice harboring a null allele display a portocaval vascular shunt throughout life. To define the ontogeny and determine the identity of this shunt, we developed a visualization approach in which three-dimensional (3D) images of the developing liver vasculature are generated from serial sections. Applying this 3D visualization approach at multiple developmental times allowed us to demonstrate that the portocaval shunt observed in Ahr-null mice is the remnant of an embryonic structure and is not acquired after birth. We observed that the shunt is found in late-stage wild-type embryos but closes during the first 48 h of postnatal life. In contrast, the same structure fails to close in Ahr-null mice and remains open throughout adulthood. The ontogeny of this shunt, along with its 3D position, allowed us to conclude that this shunt is a patent developmental structure known as the ductus venosus (DV). Upon searching for a physiological cause of the patent DV, we observed that during the first 48 h, most major hepatic veins, such as the portal and umbilical veins, normally decrease in diameter but do not change in Ahr-null mice. This observation suggests that failure of the DV to close may be the consequence of increased blood pressure or a failure in vasoconstriction in the developing liver.     

脾肾静脉分流联合断流手术治疗门静脉高压症

目的评价近端脾肾静脉分流联合断流手术治疗门静脉高压症的临床疗效。方法回顾性总结1998年2月至2008年12月我院采用脾肾静脉分流联合断流手术治疗门静脉高压症56例病例,统计术中门静脉压力改变、术后CDFI检测脾静脉及分流通道情况,并从术后并发症、肝功能、再出血三方面总结临床疗效。结果手术前后门静脉压由(37.55±5.37)cmH2O降至(25.03±4.66)cmH2O,平均下降(12.53±7.23)cmH2O(P<0.05)。术后1、3、12、24个月脾静脉及脾肾静脉分流通道血栓形成分别为0、1、2、3例;脾肾静脉分流口直径0.75～1.25cm,平均(0.98±0.37)cm;门静脉血流均为向肝血流,脾静脉血流均为逆肝血流。术后肝功能均恢复正常。术后并发症共4例,均经保守治疗后治愈或好转。2例于术后3年、5年出现上消化道大出血,经查为脾肾静脉分流通道血栓形成者。结论脾肾静脉分流联合断流手术既保留了分流术及断流术的优点,又克服了二者的缺点,是治疗门静脉高压症的一种理想术式。     

The effect of propranolol on the hyperaemic response of the hepatic artery to portal venous occlusion in the dog.

1. It has been reported that activation of beta-adrenoceptors may be responsible for the hyperaemic response of the hepatic artery to portal venous blood flow reduction. 2. The effect of beta-adrenoceptor blockade on the hepatic arterial response to portal vein occlusion was investigated in 6 anaesthetized dogs. A side-to-side portacaval shunt was established to prevent loss of venous return and arterial blood pressure during periods of portal occlusion. Measurements of hepatic arterial and portal venous blood flows were made by use of electromagnetic flow probes. 3. Intravenous propranolol injection, at a dose sufficient to block the vasodilator effect of low doses of exogenous adrenaline, did not alter the magnitude of the hyperaemic response of the hepatic artery. Propranolol also produced no change in baseline portal venous pressure. 4. It is concluded that hepatic beta-adrenoceptors are unlikely to be involved in the arterial response to portal occlusion. The absence of any reduction in basal portal venous pressure by propranolol is of interest in view of the current application of the drug in the treatment of patients with portal hypertension.     

Current approaches to the management of patients with liver cirrhosis who have acute esophageal variceal bleeding

Objective:

Esophageal variceal bleeding is the most dangerous complication in patients with liver cirrhosis, and it is accompanied by high mortality. Their treatment can be complex, and requires a multidisciplinary approach. This review examines current approaches to the management of patients with liver cirrhosis who have acute esophageal variceal bleeding.

Methods:

PubMed, Google Scholar, and Cochrane Systematic Reviews were searched for articles published between 1987 and 2015. Relevant articles were identified using the following terms: ‘esophageal variceal bleeding’, ‘portal hypertension’ and ‘complications of liver cirrhosis’. The reference lists of articles identified were also searched for other relevant publications. Inclusion criteria were restricted to the management of patients with liver cirrhosis who have acute esophageal variceal bleeding.

Results:

It is currently recommended to combine vasoactive drugs (preferable somatostatin or terlipressin) and endoscopic therapies (endoscopic band ligation as first choice, sclerotherapy if endoscopic band ligation not feasible) for the initial treatment of acute variceal bleeding. Antibiotic prophylaxis must be regarded as an integral part of the treatment. The use of a Sengstaken–Blakemore tube is appropriate only in cases of refractory bleeding if the above methods cannot be used. An alternative to balloon tamponade may be the installation of self-expandable metal stents. The transjugular intrahepatic portosystemic shunt is an extremely useful technique for the treatment of acute bleeding from esophageal varices. Although most current clinical guidelines classify it as second-line therapy, the Baveno VI workshop recommends early transjugular intrahepatic portosystemic shunt with expanded polytetrafluoroethylene-covered stents within 72?h (ideally <24?h) in patients with esophageal variceal bleeding at high risk of treatment failure (e.g. Child–Turcotte–Pugh class C?<?14 points or Child–Turcotte–Pugh class B with active bleeding) after initial pharmacological and endoscopic therapy. Urgent surgical intervention is rarely performed and can be considered only in case of failure of conservative and/or endoscopic therapy and being unable to use a transjugular intrahepatic portosystemic shunt. Among surgical operations described in the literature are a variety of portocaval anastomosis and azygoportal disconnection procedures.

Conclusions:

To improve the results of treatment for patients with liver cirrhosis who develop acute esophageal variceal bleeding, it is important to stratify patients into risk groups, which will allow one to tailor therapeutic approaches to the expected results.     

门静脉高压症择期手术的选择

目的探讨门静脉高压症手术择期的临床选择。方法总结分析2005年1月至2009年6月24例采用断流术、断流加分流术及分流加断流联合术式治疗门静脉高压症的临床资料。结果急症断流术14例,死亡2例。择期手术10例,其中断流术6例,断流加分流术4例,无手术死亡。术后随访20例,再出血3例,死于肝功能衰竭1例,无肝性脑病发生。结论脾肾静脉分流加断流的联合手术应作为治疗肝硬化PHT的首选术式[1]。     

经静脉肝内门体静脉分流术治疗门脉高血压50例

目的观察经静脉肝内门体静脉分流术治疗门脉高血压的临床疗效。方法选取100例门脉高血压患者,将其随机分为试验组和对照组各50例,试验组采用经静脉肝内门体静脉分流术治疗,对照组采用部分脾切除术进行治疗,观察两组患者的临床疗效。结果随访显示,试验组患者治疗总有效率为96%,明显优于对照组的76%,两组比较差异有统计学意义,P<0.05。结论经静脉肝内门体静脉分流术治疗门脉高血压效果较好,值得临床推广使用。     

Partial portacaval shunt with H-grafts to treat portal hypertension

Partial portosystemic shunts have been popularized because of a reported low rate of mortality and morbidity (especially encephalopathy, liver failure and occlusion). The results of partial portacaval shunts [small-diameter expanded polytetrafluoroethylene (ePTFE) H-graft portacaval shunt] were retrospectively reviewed to evaluate the clinical efficacy in the treatment of portal hypertension. Forty-three patients with portal hypertension were treated by small-diameter H-graft of ePTFE portacaval shunt from May 1995 to April 2006. Thirty-three had externally ringed grafts and ten had non-ringed ones. Ten had grafts of 10 mm in diameter and 33 had grafts of 8 mm. The left gastric artery and coronary vein were ligated in all the cases. Six had pericardial devascularization and splenectomy was performed in 42. An average decrease of free portal pressure (FPP) from (33.24 ± 4.78) cmH₂O before shunting and (13.65 ± 5.65) cmH₂O after shunting was observed. The portal blood flow was reduced by one-third of that before shunt. Thirty-eight patients survived and no upper gastro-intestinal rebleeding occurred in the follow-up period (50.5 months in average). Two were out of contact. Color Doppler ultrasonography and/or portography revealed the shunts were patent in 38 cases and were occluded in three cases (3/41, 7.3%). Encephalopathy developed in five cases (5/41, 12.2%). Partial (small-diameter ePTFE H-graft) portacaval shunting can reduce the portal pressure effectively. Majority of the hepatic flow from the portal vein can be maintained adequately. The shunts with reinforced grafts can keep a higher rate of patency. The morbidity of encephalopathy was lower than those with total shunt. The partial portacaval shunt is effective in preventing recurrent variceal bleeding.