门静脉主干缩窄附加脾静脉结扎制备犬门脉高压症模型

目的 观察犬门静脉主干缩窄加脾静脉结扎后门静脉系统的变化,为该方法能否建立一种具有脾亢的门静脉高压症大动物模型提供依据.方法 犬15条,采用门静脉主干缩窄加脾静脉结扎的方法建立模型,术前及术后每周观察实验动物血象的变化,在预定时间点分别随机选择5条犬开腹观测门静脉自由压、脾脏大小、门体侧支循环形成情况,并切取脾脏行组织病理学检查.此外,术前及术后预定时间点了解骨髓增生情况变化.结果 建模后,外周血红细胞、血小板下降,脾脏肿大明显,并且能够有效持续到第9周;术后第5、7、9周的脾脏组织病理学改变符合脾脏慢性淤血改变,而且骨髓增生情况较正常明显活跃.结论 门静脉主干缩窄加脾静脉结扎后门静脉系统的变化符合门静脉高压症的表现,尤其是脾亢状态较满意,具有良好的实验应用价值.     

一种肝前性门静脉高压症模型的制备

目的通过门静脉主干部分结扎附加3周后脾静脉缩窄及其属支结扎的方法建立犬的动物模型,观察门静脉系统变化,为该方法能否建立一种具有脾亢的门静脉高压症大动物模型提供依据。方法实验犬25只,随机分为A组(正常组,n=5)、B组(对照组,n=10)、C组(实验组,n=10)。A组仅予以剖腹探查,B组予以门静脉主干部分结扎建立模型,C组则通过门静脉主干部分结扎附加3周后脾静脉缩窄及其属支结扎的方法建立模型,建模后术前及术后每周动态观察两组动物血象的变化,B、C组在预定时间点(术后第5、第9周)分别随机选择5只动物开腹观测门静脉自由压、脾脏大小、门体侧支循环形成情况,并切取脾脏行组织病理学检查,此外,术前及术后预定时间点了解骨髓增生情况变化。结果两种方法建模后,门静脉自由压的增高明显,血常规示B组红细胞和血小板在术后3周明显低于正常值,4周后开始回升,而C组血红细胞和血小板的下降能够持续到术后第9周,且脾脏形态变化及术后脾脏组织病理学改变和骨髓增生情况证实C组较B组能够形成良好的脾功能亢进状态。结论门静脉主干部分结扎附加3周后脾静脉缩窄及其属支结扎的方法建模后门静脉系统的变化符合门静脉高压症的表现,尤其是脾亢状态合适,具有良好的科研应用价值。     

射频消融治疗继发性脾肿大、脾功能亢进可行性和安全性的实验研究

目的 评价射频消融(RFA)脾脏治疗继发性脾肿大和脾功能亢进的可行性和安全性。方法 14只健康杂种狗随机分为Ⅰ组(脾静脉结扎,n=4)和Ⅱ组(脾静脉结扎 RFA,n=10),通过结扎脾静脉主干和脾静脉属支引起淤血性脾肿大,3周末Ⅱ组剖腹行射频热能毁损脾脏。观察动物脾脏经RFA后的并发症,定期行CT扫描以及切取脾脏观察热毁损后脾脏病灶的影像学和组织病理学变化。结果 全组动物无死亡和并发症。CT显示脾静脉结扎后脾脏明显肿大并可持续2个月以上,RFA后脾脏病灶呈节段性毁损,包括高密度的坏死区和低密度的梗死区——后者称为“旁观者效应”;梗死区在RFA后4—6周内消失,残脾缩小;坏死区改变不明显。射频热能引起脾脏局部组织凝固性坏死和广泛的血栓性梗死形成。梗死区逐渐吸收、纤维化,血管闭塞、纤维素沉积和脾窦消失引起活性脾脏组织结构致密。结论 RFA治疗实验性脾肿大和脾亢是可行和安全的,将来可在开腹或腹腔镜下严格隔离脾脏周围器官后在临床安全实施。     

一种大鼠门静脉高压脾功能亢进模型的建立

目的通过门静脉缩窄联合脾静脉结扎的方法,建立大鼠门静脉高压脾功能亢进模型。方法 60只健康雄性SD大鼠按随机数字表法分为假手术组(n=20)、门静脉缩窄组(缩窄组,n=20)和门静脉缩窄联合脾静脉结扎组(联合组,n=20),其中假手术组仅予以开、关腹术,缩窄组予以单纯门静脉主干缩窄术,联合组予以门静脉缩窄联合脾静脉结扎术。造模开始前和造模后7周每周采各组动物外周血行红细胞、白细胞及血小板计数动态观察;于造模开始前和造模后第7周测量各组动物门静脉压力及脾横、长径,于造模后第7周处死动物后计算各组脾指数并观察脾脏组织的病理学变化。结果联合组大鼠外周血血小板及红细胞计数于第3周起明显低于假手术组及缩窄组(P<0.05);而3组白细胞计数各时相间差异均无统计学意义(P>0.05)。第7周时缩窄组及联合组门静脉压力均较术前明显升高(P<0.05),并且明显高于假手术组(P<0.05)。第7周时联合组的脾横径及脾长径较术前明显增大(P<0.05),并且明显大于假手术组及缩窄组(P<0.05),其脾指数亦高于假手术组及缩窄组(P<0.05)。第7周时联合组脾脏有典型的脾功能亢进的病理改变,而另2组未见明显病理改变。结论通过门静脉缩窄联合脾静脉结扎的方法,成功建立了大鼠继发性门静脉高压脾功能亢进模型,该方法手术操作简便、效果稳定,具有良好的科研应用价值。     

肝硬化基础的腹部脏器疾病外科手术治疗时脾功能亢进的处理

目的探讨脾动脉阻断下脾脏微波消融联合腹腔病变脏器切除治疗脾肿大伴脾功能亢进合并其它疾病的临床安全性及近期疗效。方法回顾分析我院16例肝炎肝硬化后脾功能亢进合并其他疾病行脾动脉阻断下脾脏微波消融联合其它腹腔病变脏器切除患者的临床资料。结果 16例患者手术均成功,术后高热4例,左侧胸腔积液8例,脾脏包膜下血肿1例,腹腔渗血1例,皮肤组织淤血2例;未发生脾脓肿、脾脏破裂、顽固性胸腹水、门静脉血栓等,所有患者顺利出院;术后两周及术后一月白细胞、血小板较术前明显升高,且有统计学意义。结论脾动脉阻断下脾脏微波消融联合腹腔病变脏器切除治疗脾肿大伴脾功能亢进合并其它疾病安全,近期疗效显著;     

脾动脉缩窄对大鼠肝硬化进程影响的实验研究

目的 探讨脾动脉缩窄对大鼠肝硬化进程的影响.方法 将96只SD大鼠随机分3组,对照组仅行开腹术;切脾组开腹行脾脏切除术;脾动脉缩窄组开腹行脾动脉缩窄术,然后腹腔注射硫代乙酰胺诱导肝硬化模型.定期处死一定数量的大鼠,动态观察大鼠血常规、肝功能、肝组织病理改变及血清Tuftsin水平变化.结果 术后对照组大鼠白细胞、红细胞和血小板逐渐下降(P＜0.05),而切脾组和脾动脉缩窄组未见明显变化(P＞0.05);切脾组与脾动脉缩窄组的肝功能损伤和肝硬化程度较同期对照组相比轻(P＜0.05);脾动脉缩窄组血清Tuftsin水平与对照组比较差异无统计学意义(P＞0.05),而切脾组Tuftsin水平显著下降(P＜0.05).结论 脾动脉缩窄术和切脾术均能有效地防止脾功能亢进的发生,从而延缓肝硬化的进展,而脾动脉缩窄术则保留了脾脏的功能.     

预结扎脾动脉腹腔镜巨脾切除术12例分析

目的:探讨预结扎脾动脉腹腔镜巨脾切除术的方法和疗效。方法:为12例巨脾伴脾功能亢进患者行腹腔镜脾切除术。术中预结扎脾动脉,超声刀解剖脾周韧带,Endo-GIA离断脾蒂。结果:12例患者均顺利完成手术,无中转开腹及并发症发生。术后血小板、白细胞均明显上升。结论:随着超声刀、Endo-GIA等先进器械的应用,预结扎脾动脉腹腔镜巨脾切除术已成为治疗巨脾、脾功能亢进的有效术式。     

脾动脉缩窄式远端脾肾分流术后免疫功能观察

为纠正Warren术后脾亢不能持久缓解之缺点，我院于2000年在Warren传统术式的基础上缩窄脾动脉而创建了脾动脉缩窄式远端脾肾静脉分流术（DSRS-SAC），临床应用证实DSRS-SAC术预防门脉高压症病人再出血及长期缓解脾功能亢进疗效确切，同时保留了脾脏的免疫功能。本文就DSRS-SAC术后机体免疫功能变化作一观察并报道如下。     

脾功能亢进与血脾屏障的研究

目的 研究脾功能亢进时血脾屏障的改变,探讨两者的相关性和脾功能亢进的发病机理.方法 收集33例肝硬化门静脉高压脾脏为试验组,20例外伤脾脏为对照组.每例脾脏选取5块组织,HE染色后计数生发中心,总生发中心数量一平均值×脾质量.统计脾脏质量,术前血常规数值.统计学计算生发中心数量与血常规数值的相关性.结果 两组比较,试验组中血常规数值显著降低,脾质量增加(平均值764.2 g),生发中心增多(平均值8817/例).生发中心的总量与血小板计数呈负相关.说明脾功能亢进程度(包括血小板和脾质量)与生发中心数量的关系.即血小板数量越少,其脾脏生发中心的总数越多,脾质量越重,生发中心数量亦越多.结论 肝硬化脾功能亢进时,脾脏中的生发中心显著增多,形态不完整,血脾屏障功能异常.血脾屏障功能异常是脾功能亢进的发病基础.     

中西医结合腹腔镜脾切除治疗脾脏疾病

目的探讨腹腔镜脾切除术,包括内结扎法与器械结扎血管法,辅以中药扶正,中西医结合治疗各种原因导致脾肿大的可行性与临床效果。方法自2007年10月至2011年2月,采用行腹腔镜脾切除术合并中西医结合治疗各种脾肿大疾病28例,包括遗传性球形红细胞增多症11例、原发性脾肿大9例、血小板减少性紫癜3例,肝硬化脾肿大5例。术前针对不同病因给予不同中药扶正、对症治疗,在腹腔镜下先游离显露脾动脉,用丝线结扎、切断,再逐一游离显露脾静脉,用丝线结扎、切断,或用Endo-GIA或者hem-o-lok等器械结扎脾门血管。用超声刀逐步游离、切断脾周围韧带,将脾脏置入污物袋,捣碎取出。术后辅以中药辅助治疗。结果2例肝硬化患者因术中出血中转开腹手术,其余均经腹腔镜完成,其中内结扎法完成9例,应用Hem-o-lok法7例,应用内镜直线切割闭合器法10例;出血量为10一25ml,平均15ml,切脾时间100～180min,平均130min;取脾时间40～60min;术中、术后无输血;术后无明显出血、腹腔感染等并发症发生。术前、术后均辅以中药扶正治疗,术后贫血得以纠正,血红蛋白2周后恢复正常,遗传性球形红细胞增多症患者血小板术后1周明显增多,辅以中药抗凝,4周后恢复正常。结论采用腹腔镜脾切除合并中西医结合治疗各种脾肿大患者微创、安全、有效;根据不同患者采用不同血管内或器械结扎法,临床效果相同,经济实用;中药扶正,提高治疗效果。     

The effects of splenic artery ligation in an experimental model of secondary hypersplenism

OBJECTIVE: To induce hypersplenism in rats by splenic vein ligation and to investigate the effects of splenic artery ligation in this model. BACKGROUND: Selective arterial embolisation and splenic artery ligation (SAL) are used in the treatment of secondary hypersplenism in some medical centres but these methods are not common. MATERIALS AND METHODS: Thirty male Saprague-Dawley rats were allocated to three groups (n = 10). The first group underwent laparotomy, the second and third groups underwent laparotomy and splenic vein ligation. At the end of the third week, laparotomy was performed in the first and second groups and splenic artery ligation in the third group. Erythrocyte, leukocyte and platelet counts were performed weekly. At the end of the sixth week, the animals were sacrificed and the spleens were taken for histopathologic examination. RESULTS: In the second and third groups, after splenic vein ligation, the erythrocyte and platelet counts were significantly reduced at the end of the second week (p < 0.01). In the second group, which underwent splenic vein ligation only, the levels remained low throughout the experiment. In the third group, after splenic artery ligation, there were rises in both erythrocyte and platelet counts; the levels were similar to the levels in the control group at three weeks after splenic artery ligation (p > 0.05). No significant changes were observed in the leukocyte counts throughout the experiment (p > 0.05). CONCLUSIONS: Splenic vein ligation successfully induces experimental secondary hypersplenism. This state can be ameliorated by splenic artery ligation.     

直接门静脉造影在门静脉高压症治疗中的作用

目的 研究直接门静脉高压症治疗中的作用。方法 采用直接门静脉造影观察１８５例门静脉高压症患者例支血管和冠状静脉解剖,根据造影结果对３５例门静脉高压症患者行经腹联合门奇断流术。结果 门静脉高压症患者显示冠状静脉２２３支,其中单支７９．４６％,双支２０．５４％,冠状静脉开口于门静脉主干、脾静脉和门脾静脉交汇处分别为６２．３３％、２７．３５％和８．０７％,出血和断流术后现出知患者主要位于门静脉主干,顽固     

Ligation of huge spontaneous porto-systemic collaterals to avoid portal inflow steal in adult living donor liver transplantation: A case-report

IntroductionIn adult living donor liver transplantation (LDLT), maintenance of adequate portal inflow is essential for the graft regeneration. Portal inflow steal (PFS) may occur due to presence of huge spontaneous porto-systemic collaterals. A surgical procedure to increase the portal inflow is rarely necessary in adult LDLT.PresentationA 52 years male patient with end-stage liver disease due to chronic hepatitis C virus infection. Preoperative portography showed marked attenuated portal vein and its two main branches, patent tortuous splenic vein, multiple splenic hilar collaterals, and large lieno-renal collateral. He received a right hemi-liver graft from his nephew. Exploration revealed markedly cirrhotic liver, moderate splenomegaly with multiple collaterals and large lieno-renal collateral. Upon dissection of the hepato-duodenal ligament, a well-developed portal vein could be identified with a small mural thrombus.The recipient portal vein stump was anastomosed, in end to end fashion, to the graft portal vein. Doppler US showed reduced portal vein flow, so ligation of the huge lieno-renal collateral that allows steal of the portal inflow. After ligation of the lieno-renal collateral, improvement of the portal vein flow was observed in Doppler US.DiscussionThere is no accepted algorithm for managing spontaneous lieno-renal shunts before, during, or after liver transplantation, and evidence for efficacy of treatments remains limited. We report a case of surgical interruption of spontaneous huge porto-systemic collateral to prevent PFS during adult LDLT.ConclusionComplete interruption of large collateral vessels might be needed as a part of adult LDLT procedure to avoid devastating postoperative PFS.     

慢性胰腺炎并发门静脉高压症的诊断与治疗

慢性胰腺炎并发门静脉高压症（PHT）的主要发病机制为脾静脉受压或血栓形成,造成脾静脉闭塞;通常同时表现慢性胰腺炎和PHT症状,慢性上腹痛及腰背部疼痛是慢性胰腺炎最常见症状,PHT的表现是不同程度的脾肿大和脾功能亢进,孤立的胃底静脉曲张、上消化道出血不多见。通过多普勒超声、CT、MRI以及血管成像多可得出明确诊断。治疗应既针对原发病又要针对门静脉高压症,强调个体化治疗。由慢性胰腺炎引起的PHT是可以治愈的。     

胰源性肝外门静脉高压症八例

目的总结胰源性左侧肝外门静脉高压症（LEPH）临床特点、诊断和治疗经验.方法回顾性分析我院收治的8例LEPH病人临床资料.结果LEPH主要表现为黑便、呕血和脾肿大、脾功能亢进,并有胰腺炎、胰腺肿瘤或胰腺外伤表现,而无肝脏疾病表现,内镜下以孤立性胃底静脉曲张为主.术前易误诊为肝硬化门脉高压症.本组病例中行单纯脾切除2例,脾切除＋胰体尾切除术5例,脾动脉结扎1例.结论胰腺疾病可致门静脉高压症,脾静脉栓塞是本病直接原因.胰腺疾病合并上消化道出血应想到本症可能,脾切除术可有效控制出血.     

肝癌合并脾功能亢进的外科治疗

目的探讨原发性肝癌合并脾功能亢进（脾亢）的外科治疗方法和疗效。方法回顾性研究我院2000年8月至2010年8月41例原发性肝癌合并脾亢手术病例,11例合并重度脾亢患者行肝癌切除及脾脏切除（脾切除组）,其中3例附加贲门周围血管离断术;30例由于中度脾亢采用了肝癌切除及脾动脉结扎术（脾动脉结扎组）。结果术后两组脾亢症状基本消除,脾切除组和脾动脉结扎组术后1周血小板、白细胞均上升,两组间差异无统计学意义（P〉0．05）。脾切除组术后有2例胸腔积液,1例切口感染,3例术后黄疸及腹水并发症,脾动脉结扎组术后腹水2例,1例切口脂肪液化,1例胸腔积液,无手术死亡病例,术后并发症在出院时消失,两组术后并发症发生率差异有统计学意义（P〈0．05）。结论原发性肝癌合并巨脾可行肝切除及脾切除,而有消化道出血史可联合行断流术,手术是安全可行的;而对合并中度脾亢,肝切除合并脾动脉结扎同样近期能达到消除脾亢症状同时减少手术创伤。     

Warren shunt combined with partial splenectomy for children with extrahepatic portal hypertension, massive splenomegaly, and severe hypersplenism

Purpose

To establish the importance of shunt surgery combined with partial resection of the spleen for selected pediatric patients with extra-hepatic portal vein obstruction (EHPVO), enormous splenomegaly and severe hypersplenism. Severe hypersplenism is often refractory to treatment with endoscopic sclerotherapy or band ligation and shunt surgery; however, to our knowledge, this is the first such study to be published.

Methods

Distal splenorenal shunt with partial resection of the spleen was performed in 16 of 60 children treated for EHPVO in the Gastroenterology Department of our hospital. Upper gastrointestinal endoscopy had shown esophageal varices of varying grade in all patients and band ligation or endoscopic sclerotherapy had been done for children with a history of bleeding. The indications for surgery were pain and discomfort caused by a large spleen (5–15 cm below the costal margin) and symptomatic hypersplenism with leucopenia, thrombocytopenia, and anemia. Partial resection of the spleen was performed, starting with ligation of the branches and tributaries of the caudal two-thirds. When an ischemic line demarcated the splenic parenchyma, it was transected using electrocautery or LigaSure, leaving 20–30 % of splenic tissue. After the spleen resection, a Warren shunt was performed. Platelet and white blood cell counts and liver function tests were performed before and after the operation. Growth was assessed using SD scores (z scores) for height, weight, and body mass index at the time of surgery and 1 year later.

Results

Postoperative recovery was uneventful and the leukocyte and platelet counts normalized. The shunt patency rate was 100 %. Two cases of shunt stenosis were treated successfully with percutaneous angioplasty. There was no postoperative mortality. During the follow-up period, from 1 to 7 years, all 16 children were asymptomatic, with improved quality of life, growth, and nutrition. No episodes of variceal bleeding, sepsis or encephalopathy occurred.

Conclusion

Our results demonstrate that shunt surgery with partial resection of the spleen is effective and safe for pediatric patients with massive splenomegaly and severe hypersplenism secondary to EHPVO.