联合断流术治疗门静脉高压症并急性上消化道大出血

目的探讨门静脉高压症合并急性上消化道大出血的治疗方法.方法对1981～1999年收治的60例门静脉高压症并消化道大出血患者的临床资料进行回顾性分析.结果本组男42例,女18例.年龄25～63岁.均为肝炎后肝硬化、门静脉高压症并食管及胃底静脉曲张破裂急性上消化道大出血病人.均采取急诊脾切除、贲门周围血管离断术.本组成功止血率100%,围手术期死亡率6.7%(4/60).其中出血48 h内手术者死亡率2.9%(1/35),并发症发生率34.3%(12/35),超过48 h手术者死亡率12.0%(3/25),并发症发生率80.0%(20/25).结论对于门静脉高压症并上消化道出血施行急诊脾切除、贲门周围血管离断术治疗是可行的.早期手术(<48h)比保守治疗无效后再被迫手术效果更好.     

门静脉高压症食管下段胃底曲张静脉破裂大出血的急诊断流术

目的　探讨胃底贲门周围血管离断术治疗门静脉高压症上消化道大出血的体会。方法　对 64例因门静脉高压症食管下段胃底曲张静脉破裂出血而实行急诊断流术的患者的临床资料进行回顾性分析。结果　手术止血率 10 0 % ,术后死亡 5例。随诊 6月～ 10年 ,再出血患者 5例。结论　胃底贲门周围血管离断术是治疗门静脉高压症上消化道大出血的首选术式     

贲门周围血管离断术治疗门静脉高压症693例临床报告

目的总结贲门周围血管离断术治疗门静脉高压症的效果。方法回顾性分析自1978年至2002年行贲门周围血管离断术693例的临床资料。结果急诊手术84例,手术止血率76.2%(64/84),手术总死亡率7.2%(50/693),主要死亡原因为上消化道大出血、腹腔大出血、肝性脑病和肝功能衰竭。平均随访时间3.5年,5年生存率92%、10年生存率60%。术后复发性出血率7%(5年)和12.5%(10年)。肝性脑病发生率3%(5年)和5%(10年)。远期主要死亡原因:上消化道大出血15例,肝功能衰竭23例,并发原发性肝癌7例。结论必须严格掌握手术适应证和手术时机,断流术彻底是提高疗效的关键。     

精准断流术治疗门静脉高压症上消化道出血疗效分析

目的探讨精准断流术治疗门静脉高压症上消化道出血的疗效。方法回顾性分析2005~2012年期间施行精准断流术治疗门静脉高压症上消化道出血病人43例,观察该组病人手术前后血象、肝功能、并发症等指标,术后对病人进行长期随访,观察再出血率和生存情况。结果手术止血率为100%,围手术期无再出血及死亡病例。围手术期术后脾功能亢进得到有效治疗(P0.05);术后发生胃潴留2例(3.7%),手术创面渗血2例(3.7%),均经保守治疗后痊愈;术后门静脉超声检查均未发现门静脉血栓形成。43例病人全部顺利出院,术后住院时间为7~34 d,平均(11.2±5.7)d。43例中有40例获得随访,随访率为93.0%,随访时间为8~73个月,平均(49.2±10.5)月。其中1年再出血率为2.5%(1/40),1年死亡率为5.0%(2/40)。总体再出血率为17.5%(7/40),总体死亡率为22.5%(9/40),死亡原因为上消化道出血2例、肝衰竭7例,其中合并肝细胞肝癌2例。结论精准断流术是治疗门静脉高压症上消化道出血的一种有效术式。     

近段胃壁内外双重断流术治疗门静脉高压症出血的远期疗效

目的分析近段胃壁内外双重断流术式治疗门静脉高压症致上消化道出血的远期疗效。方法 1989—2008年笔者对住院治疗的367例肝硬化门静脉高压症致上消化道出血患者行壁内外双重断流术,择期手术309例,急诊手术58例;随访1~19年,平均随访16年。结果急诊手术止血率100%,术中断流后门静脉压力平均下降4.3 cm H2O,术后6~19年再出血共8例,再出血率2.5%。存活率1~5年,6~10年,11~19年分别为83.05%,91.85%,92.80%。结论近段胃壁内外双重断流术式治疗门静脉高压症致上消化道出血即时止血率高、并发症少、再出血率低、长期生存率高,是治疗门静脉高压症致上消化道出血安全、有效的重要手术方法。     

肝癌合并门静脉高压症的同期联合手术治疗(附19例报告)

目的　肝癌合并门静脉高压症同期联合手术治疗的方法和疗效。方法　回顾性分析1994年 8月至 2 0 0 2年 2月施行肝癌和门静脉高压症同期联合手术治疗 19例。结果　除 1例于术后 4周因并发肝肾综合征及上消化道出血死于多器官功能衰竭 (手术死亡率 5 .2 6 % )外 ,其余 18例皆康复出院 ,术后并发症发生率为 4 .1% (8 19)。随访中死亡 11例 ,死亡原因 :肝癌复发 3例 ,肝功衰竭 5例 ,上消化道出血 3例。术后 1、2、3年生存率分别为 79.8%、2 8.6 %、0 %。结论　只要合理掌握手术适应证和术式 ,对肝癌合并门静脉高压症施行同期联合手术治疗是安全的 ,可望延长病人的生存期     

TIPS在脾切除治疗门静脉高压症后反复出血病例中的临床应用

目的总结经颈静脉肝内门体静脉分流术(TIPS)治疗未合并肝癌的门静脉高压症患者行脾切除术后反复上消化道出血的疗效。方法对未合并肝癌或胆管癌的门静脉高压症合并上消化道大出血患者行脾切除术后复发出血患者行TIPS术治疗,并随访1～5年(平均3.2年)的资料进行总结与分析。结果 36例脾切除术后再出血者行TIPS术,手术均获成功,围手术期死亡率为2.78%(1/36),死亡原因是肝性脑病。随访期间患者术后再次复发出血率为5.71%(2/35)。结论 TIPS对脾切除治疗门静脉高压症后反复出血病例的效果良好。     

门静脉高压症并发上消化道出血138例手术治疗分析

目的总结门脉高压症并发上消化道出血的临床治疗经验。方法回顾性分析我院2006年1月至2011年6月138例门静脉高压并发上消化道出血患者的临床资料。结果本组本组138例,61例因保守治疗无效或效果差而行急诊手术,77例经保守治疗病情稳定后行择期手术,术后上消化道出血均停止。急诊手术的手术并发症发生率、术后再出血率两组间差异无统计学意义,但急诊手术对术后肝脏功能有一定影响,术后2月内死亡2例,随访5年死亡5例。结论脾切除加门奇断流术治疗门静脉高压食管胃底静脉曲张破裂大出血是安全有效的治疗方法,止血效果确切、手术时机的把握和围术期处理是急诊手术成功的关键。     

肝硬化门静脉高压症上消化道大出血的手术时机选择

目的 探讨肝硬化门静脉高压症上消化道大出血患者的手术时机和疗效.方法 回顾性分析2006年1月至2012年1月我院收治的319例肝硬化门静脉高压症性上消化道大出血患者的临床资料.60例仅行保守治疗(A组),84例保守治疗无效后急诊行脾切除加贲门周围血管离断术(B组),175例保守治疗成功止血后择期行脾切除加贲门周围血管离断术(C组).结果 B、C组术后并发症发生率分别为15.7%,2.9%,差异有统计学意义(P＜0.05);A、B、C三组的死亡率分别为53.3%(32/60),16.7%(14/84),2.3%(4/175),组间比较差异有统计学意义(P＜0.05).结论 肝硬化门静脉高压症上消化道大出血患者经非手术治疗48 h后无活动性出血可行择期手术治疗,如经保守治疗无效后应尽早行急诊手术治疗.     

改良Walker′s术治疗门静脉高压症术后再出血的体会

目的回顾评价改良的经胸食管横断术（改良Walker＇s术）方式治疗门静脉高压症术后再出血的效果。方法根据Sugiura术的血液动力学原理,将经胸食管横断术进行改良（改良Walker＇s术）,在食管下段较低位置阻断食管静脉血流的同时,离断腹段残留或复发的冠状静脉属支。结果本组共52例,择期手术48例,无手术死亡;急症手术4例,1例死于肝功能衰竭。本组中5例失访,有45例获得长期随访,结果在术后1年5个月因肝功能衰竭死亡1例,术后2～3年2例死于肝癌;术后4～5年3例因肝功能衰竭、肝肾综合症死亡;存活5年以上者有39例,5年生存率75%（9/52）。有1例患者已经再手术后生存23年。结论改良Walker＇s术适用于门静脉高压症术后再出血患者,该手术简单易掌握、止血可靠,近期、远期效果良好。     

Transabdominal Extensive Esophagogastric Devascularization with Gastroesophageal Stapling for Management of Noncirrhotic Portal Hypertension: Long-term Results

Outside Japan portosystemic shunts have been favored as the surgical procedure of choice for the management of portal hypertension of noncirrhotic etiology. Devascularization procedures have resulted in high rebleed rates probably owing to a limited extent of devascularization. We performed this study to assess the efficacy of our modification of Sugiura's procedure for long-term control of variceal bleeding in patients with noncirrhotic portal hypertension. Forty-six patients with extrahepatic portal venous obstruction (EHPVO) and 22 with noncirrhotic portal fibrosis (NCPF) were subjected to transabdominal extensive esophagogastric devascularization with esophageal or gastric stapled transection (modified Sugiura's procedure), 38 in an emergency situation and 30 electively. Follow-up endoscopies were performed every 6 months. Operative mortality, morbidity, variceal status, and causes of recurrent bleeding were evaluated. The postoperative mortality was 4%. Early procedure-related complications were seen in 6%, and esophageal strictures formed in 7 of 45 survivors undergoing esophageal transection (15%). Over a mean ± SD follow-up of 53 ± 34 months, 95% of patients were free of varices. Seven survivors (11%) had a rebleed, but only 5% were due to varices (two esophageal, one gastric). Six (9%) patients developed gastropathy. The 5-year survival was 88%. The modified Sugiura's procedure is safe and effective for long-term control of variceal bleeding especially in the emergency setting and in patients with anatomy unsuitable for shunt surgery or if surgical expertise for a shunt operation is not available.     

Current status of the distal splenorenal shunt in China

Herein we report the results and current status of the distal splenorenal shunt (DSRS) in China. From June 1979 to June 1989, the DSRS was performed in 302 patients with esophagogastric varices. Among a group of 249 patients, 112 were in Child's class A, 97 were in class B, and 40 were in class C. The cause of portal hypertension was posthepatic cirrhosis in 217 patients, schistosomiasis in 28 patients, alcoholic cirrhosis in 3 patients, and biliary cirrhosis in 1 patient. Therapeutic selective shunts were performed in 200 patients with variceal bleeding, and 102 patients received prophylactic shunts. Emergency operations were performed in 10 patients. The original Warren shunt was performed in 264 patients, and various modifications in 38 patients. Simultaneous ligation of the splenic artery was performed in 202 patients. The overall operative mortality rate was 6%. A 3-month to 10-year follow-up demonstrated an 8% recurrent bleeding rate, a 1% incidence of encephalopathy, and a survival rate ranging from 72.3% to 100%. From the preliminary results obtained, we conclude that DSRS is effective and safe in the treatment of esophagogastric variceal bleeding. It can also be used as a prophylactic procedure in Child's class A and B patients.     

The changing spectrum of treatment for variceal bleeding.

OBJECTIVE: The objective of this study was to assess the impact of endoscopic therapy, liver transplantation, and transjugular intrahepatic portosystemic shunt (TIPS) on patient selection and outcome of surgical treatment for this complication of portal hypertension, as reflected in a single surgeon's 18-year experience with operations for variceal hemorrhage. SUMMARY BACKGROUND DATA: Definitive treatment of patients who bleed from portal hypertension has been progressively altered during the past 2 decades during which endoscopic therapy, liver transplantation, and TIPS have successively become available as alternative treatment options to operative portosystemic shunts and devascularization procedures. METHODS: Two hundred sixty-three consecutive patients who were surgically treated for portal hypertensive bleeding between 1978 and 1996 were reviewed retrospectively. Four Eras separated by the dates when endoscopic therapy (January 1981), liver transplantation (July 1985), and TIPS (January 1993) became available in our institution were analyzed. Throughout all four Eras, a selective operative approach, using the distal splenorenal shunt (DSRS), nonselective shunts, and esophagogastric devascularization, was taken. The most common indications for nonselective shunts and esophagogastric devascularization were medically intractable ascites and splanchnic venous thrombosis, respectively. Most other patients received a DSRS. RESULTS: The risk status (Child's class) of patients undergoing surgery progressively improved (p = 0.001) throughout the 4 Eras, whereas the need for emergency surgery declined (p = 0.002). The percentage of nonselective shunts performed decreased because better options to manage acute bleeding episodes (sclerotherapy, TIPS) and advanced liver disease complicated by ascites (liver transplantation, TIPS) became available (p = 0.009). In all Eras, the operative mortality rate was directly related to Child's class (A, 2.7%; B, 7.5%; and C, 26.1 %) (p = 0.001). As more good-risk patients underwent operations for variceal bleeding, the incidence of postoperative encephalopathy decreased (p = 0.015), and long-term survival improved (p = 0.012), especially since liver transplantation became available to salvage patients who developed hepatic failure after a prior surgical procedure. There were no differences between Eras with respect to rebleeding or shunt occlusion. Distal splenorenal shunts (p = 0.004) and nonselective shunts (p = 0.001) were more protective against rebleeding than was esophagogastric devascularization. CONCLUSIONS: The sequential introduction of endoscopic therapy, liver transplantation, and TIPS has resulted in better selection and improved results with respect to quality and length of survival for patients treated surgically for variceal bleeding. Despite these innovations, portosystemic shunts and esophagogastric devascularization remain important and effective options for selected patients with bleeding secondary to portal hypertension.     

Bleeding esophagogastric varices from extrahepatic portal hypertension: 40 years' experience with portal-systemic shunt

BACKGROUND: This article discusses the largest and longest experience reported to date of the use of portal-systemic shunt (PSS) to treat recurrent bleeding from esophagogastric varices caused by extrahepatic portal hypertension associated with portal vein thrombosis (PVT). STUDY DESIGN: Two hundred consecutive children and adults with extrahepatic portal hypertension caused by PVT who were referred between 1958 and 1998 after recovering from at least two episodes of bleeding esophagogastric varices requiring blood transfusions were managed according to a well-defined and uniformly applied protocol. All but 14 of the 200 patients were eligible for and received 5 or more years of regular followup (93%); 166 were eligible for and received 10 or more years of regular followup (83%). RESULTS: The etiology of PVT was unknown in 65% of patients. Identifiable causes of PVT were neonatal omphalitis in 30 patients (15%), umbilical vein catheterization in 14 patients (7%), and peritonitis in 14 patients (7%). The mean number of bleeding episodes before PSS was 5.4 (range 2 to 18). Liver biopsies showed normal morphology in all patients. The site of PVT was the portal vein alone in 134 patients (76%), the portal vein and adjacent superior mesenteric vein in 10 patients (5%), and the portal and splenic veins in 56 patients (28%). Postoperative survival to leave the hospital was 100%. Actuarial 5-year, 10-year, and 15-year survival rates were 99%, 97%, and 95%, respectively. Five patients (2.5%), all with central end-to-side splenorenal shunts, developed thrombosis of the PSS, and these were the only patients who had recurrent variceal bleeding. During 10 or more years of followup, 97% of the eligible patients were shown to have a patent shunt and were free of bleeding. No patient developed portal-systemic encephalopathy, liver function tests remained normal, liver biopsies in 100 patients showed normal architecture, hypersplenism was corrected. CONCLUSION: PSS is the only consistently effective therapy for bleeding esophagogastric varices from PVT and extrahepatic portal hypertension, resulting in many years of survival, freedom from recurrent bleeding, normal liver function, and no encephalopathy.     

Esophagogastric variceal hemorrhage: its treatment by percutaneous transephatic coronary vein occlusion.

The angiographic technique percutaneous transhepatic coronary vein occlusion was used to treat esophagogastric variceal bleeding in 38 patients. There were two categories of patients: those actively bleeding who had not been controlled by continuous vasopressin infusion and/or Blakemore tube tamponade, and those with portal hypertension who were not actively bleeding at the time of transhepatic portal venography but who were at high risk for recurrent variceal hemorrhage. Coronary vein occlusion was achieved in 33 patients by (1) metal clip and cotton devices(one); (2) balloon catheter occlusion (two); (3) heat-treated autogenous clot and powdered absorbable gelatin sponge (Gelfoam) (13); and (4) Gelfoam strips soaked in sodium tetradecyl sulfate (17). Percutaneous coronary vein occlusion was effective in controlling 81% of the patients with actively bleeding varices. In patients who were not actively bleeding, percutaneous transhepatic coronary vein occlusion seemed to afford good protection for recurrent variceal hemorrhage.     

脾切除贲门周围血管离断术治疗门静脉高压症的疗效

目的 总结采用脾切除贲门周围血管离断术治疗门静脉高压症的经验和分析其疗效。方法 从１９７２年５月至１９９９年１０月,共５０８例门静脉高压症患者行该术式治疗,其中３８９例为肝炎后肝硬化,１４１例为晚期血吸虫病或合并慢性病毒性肝炎。结果 止血率９６．９％,总的手术死亡率为４．５％。主要死亡原因为上消化道出血,腹腔内出血,肝衰和肝肾综合症。平均随访时间为３．８年。５年存在率为９４．１％、１０年为７０．７     

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??Surgical therapy procedure in cirrhosis with portal hypertension WU Zhi-yong, CHEN Wei. Department of General Surgery, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200127, China
Corresponding author??WU Zhi-yong, E-mail??zhiyongwu@gmail.com
Abstract Bleeding from esophagogastric varices is the most life-threatening complication of portal hypertension, which is the main target of traditional surgical therapy. It has been reached a consensus that non-operative therapy is primary during the period of acute variceal bleeding, such as pharmacotherapy, endoscopic therapy, triplelumen tube balloon tamponade and so on. In the case of refractory bleeding, emergency operation is suitable in patients provided that the liver dysfunction is not too severe ( Child- Pugh class A or B ). Devascularization is the most suitable choice in emergency operation so long as there is hepatopetal blood flow in the portal vein. Transjugular intrahepatic portosystem shunt (TIPS) is suitable for the patients of Child-Pugh class C who are in emergency state. Most patients who survive a first variceal hemorrhage episode should receive surgical treatment to prevent recurrent episodes. The etiological factor(s) should be defined before operation, and it also should be evaluated that the hepatic functional reserve, degree of portal hypertension and hemodynamics of the liver and portal system. Mainly for the traditional surgical method includes devascularization, shunt surgery and shunt combined with devascularization surgery. We emphasize that selection of operative method must be based on portal vein hemodynamics, and the operative modality must have a definite hemodynamic status. Among those who bleed in portal hypertension, patients with only liver function Child-Pugh class C who can not be improved by medical treatment (end-stage liver disease) are suitable for liver transplantation.     

肝硬化门静脉高压症食管胃底曲张静脉破裂出血医院内死亡原因分析

摘要：目的:探讨肝硬化门静脉高压症食管胃底曲张静脉破裂出血患者住院期间的死亡原因。方法:对近 3年收治的186例患者及在住院期内死亡的24例患者的临床资料进行回顾性分析。结果:186中择期手术130例，3例（2.31 %）因术后肝衰竭或其他并发症死亡；急诊手术28例，术后因肝衰竭或其他并发症死亡5例（17.86 %）；未行手术治疗28例，16例死亡，其中12例死于出血无法控制。结论:大出血非手术治疗无法控制而又未及时手术是导致肝硬化门静脉高压症食管胃底曲张静脉破裂出血患者最重要的医院内死亡原因，对此类患者及时采取急诊手术对降低门静脉高压症大出血患者的病死率具有重要意义。     

Bleeding esophagogastric varices from extrahepatic portal hypertension: 40 years’ experience with portal-systemic shunt

Background:

This article discusses the largest and longest experience reported to date of the use of portal-systemic shunt (PSS) to treat recurrent bleeding from esophagogastric varices caused by extrahepatic portal hypertension associated with portal vein thrombosis (PVT).

Study Design:

Two hundred consecutive children and adults with extrahepatic portal hypertension caused by PVT who were referred between 1958 and 1998 after recovering from at least two episodes of bleeding esophagogastric varices requiring blood transfusions were managed according to a well-defined and uniformly applied protocol. All but 14 of the 200 patients were eligible for and received 5 or more years of regular followup (93%); 166 were eligible for and received 10 or more years of regular followup (83%).

Results:

The etiology of PVT was unknown in 65% of patients. Identifiable causes of PVT were neonatal omphalitis in 30 patients (15%), umbilical vein catheterization in 14 patients (7%), and peritonitis in 14 patients (7%). The mean number of bleeding episodes before PSS was 5.4 (range 2 to 18). Liver biopsies showed normal morphology in all patients. The site of PVT was the portal vein alone in 134 patients (76%), the portal vein and adjacent superior mesenteric vein in 10 patients (5%), and the portal and splenic veins in 56 patients (28%). Postoperative survival to leave the hospital was 100%. Actuarial 5-year, 10-year, and 15-year survival rates were 99%, 97%, and 95%, respectively. Five patients (2.5%), all with central end-to-side splenorenal shunts, developed thrombosis of the PSS, and these were the only patients who had recurrent variceal bleeding. During 10 or more years of followup, 97% of the eligible patients were shown to have a patent shunt and were free of bleeding. No patient developed portal-systemic encephalopathy, liver function tests remained normal, liver biopsies in 100 patients showed normal architecture, hypersplenism was corrected.

Conclusion:

PSS is the only consistently effective therapy for bleeding esophagogastric varices from PVT and extrahepatic portal hypertension, resulting in many years of survival, freedom from recurrent bleeding, normal liver function, and no encephalopathy.