脾动脉栓塞后脾亢复发再行脾切除术12例报告

目的 探讨脾动脉栓塞术的效果以及脾动脉栓塞术后脾切除的手术方法及经验.方法 对2001年1月至2008年12月51例脾动脉栓塞术后12例脾亢复发再行脾切除进行回顾总结.结果 12例脾切除均获得成功,手术时间90～240 min,平均输血810ml,1例术后胰漏,引流4周后治愈,1例术后14个月发生上消化道出血行肠腔分流.结论 脾动脉栓塞应严格掌握适应证,栓塞术后再行脾切除术难度大.     

完全腹腔镜脾切除42例临床经验总结

Objective To explore the surgical skills and clinical efficacy of laparoscopic splenectomy (LS). Methods The operative duration, perioperative blood loss and postoperative complications were determined in 42 patients receiving LS in our hospital from October 2006 to May 2008 were retrospectively analyzed. Of the 42 patients, 12 suffered from splenomegaly due to blood disease, 1 from splenic tuberculosis, 1 from splenic cyst, 4 from traumatic splenic rupture,1 from malignant lymphoma and 23 from hypersplenism due to portal hypertension. Results LS was successfully performed in all the 42 patients. The mean perioperative blood loss was (300±110.60)ml, average operative duration (170±45.65) min (60-260 min) and mean postoperative inhospitalization duration (8.10±3.52)d. There was no severe complication after the operation. Conclusion For most types of splenic diseases, LS is safe and feasible. It is crucial to manage the splenic pedicle according to disease type, size, morphology and splenic hilus.     

完全腹腔镜脾切除42例临床经验总结

Objective To explore the surgical skills and clinical efficacy of laparoscopic splenectomy (LS). Methods The operative duration, perioperative blood loss and postoperative complications were determined in 42 patients receiving LS in our hospital from October 2006 to May 2008 were retrospectively analyzed. Of the 42 patients, 12 suffered from splenomegaly due to blood disease, 1 from splenic tuberculosis, 1 from splenic cyst, 4 from traumatic splenic rupture,1 from malignant lymphoma and 23 from hypersplenism due to portal hypertension. Results LS was successfully performed in all the 42 patients. The mean perioperative blood loss was (300±110.60)ml, average operative duration (170±45.65) min (60-260 min) and mean postoperative inhospitalization duration (8.10±3.52)d. There was no severe complication after the operation. Conclusion For most types of splenic diseases, LS is safe and feasible. It is crucial to manage the splenic pedicle according to disease type, size, morphology and splenic hilus.     

脾切除对活体肝移植术后肝脏血流动力学的影响

目的 研究活体肝移植联合脾脏切除术后患者肝脏血流动力学变化情况.方法 回顾性分析2006年8月至2009年3月开展的66例活体肝移植手术患者的病例资料,肝移植时行脾切除者共22例(脾切除组),年龄(45±11)岁,按1∶2的比例随机抽取同期具有可比性的肝移植时未行脾切除的44例患者作为对照组,年龄(44±10)岁,对比分析移植术后两组间患者肝脏血流动力学变化.结果 术前、术后1 d保留脾脏组和脾切除组门静脉血流速度分别为(12±2)cm/s和(11±3)cm/s、(35±18)cm/s和(32±17)cm/s,两组术后门静脉血流速度均显著大于术前水平(P＜0.05),术后1周两组肝右静脉血流速度分别为(44±18)cm/s和(31±15)cm/s,术后保留脾脏组肝右静脉血流速度明显大于脾切除组(P＜0.05),术后2周两组肝动脉血流速度分别为(18±8)cm/s和(26±7)cm/s,肝动脉阻力系数分别为0.66±0.13和0.57±0.12,1周后脾切除组肝动脉血流速度明显大于保留脾脏组(P＜0.05),而肝动脉阻力系数明显小于后者(P＜0.05).结论 活体肝移植联合脾切除术后肝脏的血流动力学情况优于单纯活体肝移植术式.

Abstract：

Objective To investigate the changes of hepatic hemodynamics in patients with splenectomy plus living donor liver transplantation (LDLT). Methods The data of 66 patients received LDLT from August 2006 to March 2009 were analyzed retrospectively:22 cases received splenectomy with LDLT (splenectomy group) and aged (45±11) years. Forty-four comparable cases received LDLT only in the mean time were selected as control group and aged (44±10) years. Comparative analysis was performed between the two groups with respect to the changes of hepatic hemodynamics after transplantation.Results Blood velocity in portal vein in control group and splenectomy group at 1 day before and after the transplantation were (12 ±2) cm/s vs. (11+3) cm/s, (35±18) cm/s vs. (32 ± 17) cm/s, respectively. Postoperative blood velocity in portal vein in both groups increased significantly than the preoperative level ( P ＜ 0.05).Blood flow velocity in right hepatic vein in both groups at 1 week after the treatment were (44±18)cm/s and (31±15) cm/s(P＜0.05), respectively. Blood flow velocity in hepatic artery in both groups 2 weeks after the operation were (18±8) cm/s vs. (26±7) cm/s(P＜0.05) and resistance coefficient of hepatic artery were 0.66±0.13 vs. 0.57±0.12 (P＜0.05), respectively. Conclusion Hepatic hemodynamics in patients received LDLT plus splenectomy is superior to that in patients received LDLT only.     

前入路分层解剖腹腔镜原位脾切除术的临床应用

目的 探讨前入路分层解剖腹腔镜下脾切除术(LS)的应用价值和临床疗效.方法 2007年12月至2009年7月我科共开展27例LS,回顾分析前入路分层解剖LS的临床资料.结果 除1例因胰尾肥大出血,中转剖腹行脾脏切除术外,其余手术均在腹腔镜下完成.切除脾脏长径8～20 cm,6例患者发现副脾(6/27,22.2%),平均手术时间125 min,平均术中失血量90 ml,平均术后住院时间5.5 d.结论 前人路分层解剖可快速顺利完成LS操作,无需过多翻弄脾脏,可减少意外损伤,节约手术时间,值得临床推广应用.

Abstract：

Objective To study the role of laparoscopic splenectomy (LS) using the anterior approach with sequential layered dissection. Methods From December 2007 to July 2009, we performed 27 LS using the anterior approach with sequential layered dissection. The clinical data were retrospectively analyzed. Results The range of splenic length was 8-20 cm. Accessory spleen was found in 6 patients (22.2%). The mean operative time was 125 mins. The mean intraoperative blood loss was 90 ml, and the mean postoperative stay was 5.5 days. Conclusions Laparoscopic splenectomy using the anterior approach with sequential layered dissection could be carried out smoothly and rapidly. It reduced accidental injuries and shortened the operative time.     

脾动脉栓塞治疗外伤性脾破裂28例临床疗效观察

目的 探讨脾动脉栓塞术(splenic artetial embolization,SAE)对外伤性脾破裂的治疗效果及并发症的处理.方法 采用SeIdiniger法行脾动脉栓塞治疗外伤性脾破裂共28例.结果 所有患者出血立即停止,其中4例行2次栓塞.28例均有脾区疼痛.22例发热.脾动脉栓塞5天后血小板、白细胞上升近1倍,7天后恢复至正常范围.28例随访6～36个月.查免疫球蛋白、CT等结果满意,未有再出血及暴发性感染(overwhelming postsplenectomy infection,OPSI)发生.结论 脾动脉栓塞不但有良好的止血作用.而且能使患者避免手术切脾,又能保留脾脏的免疫功能,可在非手术治疗失败时选用,是治疗外伤性脾破裂的一种有效治疗方法.     

部分脾栓塞术治疗外伤性脾破裂的临床应用

目的 探讨部分脾栓塞术(partial splenic embolization,PSE)治疗外伤性脾破裂的治疗效果.方法 回顾性分析2013年1月至2015年1月28例行开腹脾切除术治疗外伤性脾破裂病人的临床资料及同期开展的27例行PSE治疗外伤性脾破裂病人的临床资料并行对比分析.结果 行开腹脾切除术治疗组28例均痊愈.行PSE治疗组27例中,26例顺利完成选择性出血血管栓塞,其中1次栓塞成功25例,再次栓塞成功1例,无继发出血及开腹手术病例;1例栓塞过程中发现脾动脉主干受损,行脾动脉主干栓塞控制出血后立即中转开腹行手术处理;均痊愈出院.结论 PSE是治疗外伤性脾破裂的一种有效、微创的方法,且保留了脾脏功能.     

脾切除贲门周围血管离断术后肝脏血流动力学和储备功能的变化

Objective To observe changes of hepatic hemodynamics and hepatic functional reserve after splenectomy and periesophagogastric devascularization. Methods From July 2006 to August 2007, thirty patients with portal hypertension caused by hepatitis B cirrhosis underwent splenectomy and periesophagogastric devascuiarization. The PVPG (portal venous pressure gradient) was measured by inductor continually during operation. The HAF (hepatic artery flow), PVF (portal venours flow) and hepatic arterial RI(resistant index) were measured with Doppler sonography. The EHBF(effective hepatic blood flow) and ICGR15 (indocyaninegreen retention rate at 15 minutes) were obtained respectively by indocyaninegreen clearance test before and after the operation. Results PVPG after laparotomy (19±4) mm Hg, ligating the splenic artery(14±4) mm Hg, splenectomy(14±3)mm Hg and periesophagogastric devascularization (12±4) mm Hg showed a tendency to decrease progressively. The PVF decreased [from (42±14) ml/s to (16±8) ml/s] and HAF increased in compensation after operation. The EHBF increased [from (0.48±0.10) L/min to (0.56±0.10) L/min], and the ICGR15 decreased (from 23%±8% to 18%±4%) postoperatively. Conclusion After splenectomy and periesophagogastric devascularization, the hepatic functional reserve improves at least in a short term notwithstanding the decrease of PVPG and PVF.     

脾切除贲门周围血管离断术后肝脏血流动力学和储备功能的变化

Objective To observe changes of hepatic hemodynamics and hepatic functional reserve after splenectomy and periesophagogastric devascularization. Methods From July 2006 to August 2007, thirty patients with portal hypertension caused by hepatitis B cirrhosis underwent splenectomy and periesophagogastric devascuiarization. The PVPG (portal venous pressure gradient) was measured by inductor continually during operation. The HAF (hepatic artery flow), PVF (portal venours flow) and hepatic arterial RI(resistant index) were measured with Doppler sonography. The EHBF(effective hepatic blood flow) and ICGR15 (indocyaninegreen retention rate at 15 minutes) were obtained respectively by indocyaninegreen clearance test before and after the operation. Results PVPG after laparotomy (19±4) mm Hg, ligating the splenic artery(14±4) mm Hg, splenectomy(14±3)mm Hg and periesophagogastric devascularization (12±4) mm Hg showed a tendency to decrease progressively. The PVF decreased [from (42±14) ml/s to (16±8) ml/s] and HAF increased in compensation after operation. The EHBF increased [from (0.48±0.10) L/min to (0.56±0.10) L/min], and the ICGR15 decreased (from 23%±8% to 18%±4%) postoperatively. Conclusion After splenectomy and periesophagogastric devascularization, the hepatic functional reserve improves at least in a short term notwithstanding the decrease of PVPG and PVF.     

脾切除贲门周围血管离断术后肝脏血流动力学和储备功能的变化

Objective To observe changes of hepatic hemodynamics and hepatic functional reserve after splenectomy and periesophagogastric devascularization. Methods From July 2006 to August 2007, thirty patients with portal hypertension caused by hepatitis B cirrhosis underwent splenectomy and periesophagogastric devascuiarization. The PVPG (portal venous pressure gradient) was measured by inductor continually during operation. The HAF (hepatic artery flow), PVF (portal venours flow) and hepatic arterial RI(resistant index) were measured with Doppler sonography. The EHBF(effective hepatic blood flow) and ICGR15 (indocyaninegreen retention rate at 15 minutes) were obtained respectively by indocyaninegreen clearance test before and after the operation. Results PVPG after laparotomy (19±4) mm Hg, ligating the splenic artery(14±4) mm Hg, splenectomy(14±3)mm Hg and periesophagogastric devascularization (12±4) mm Hg showed a tendency to decrease progressively. The PVF decreased [from (42±14) ml/s to (16±8) ml/s] and HAF increased in compensation after operation. The EHBF increased [from (0.48±0.10) L/min to (0.56±0.10) L/min], and the ICGR15 decreased (from 23%±8% to 18%±4%) postoperatively. Conclusion After splenectomy and periesophagogastric devascularization, the hepatic functional reserve improves at least in a short term notwithstanding the decrease of PVPG and PVF.     

原发性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的合理治疗方法。方法 1994年1月至2004年12月我院收治67例原发性肝癌合并脾功能亢进患者，17例行肝切除联合脾切除，7例行单纯肝切除，43例行肝动脉栓塞化疗联合脾动脉栓塞。结果 肝切除联合脾切除组术后30d患者脾功能亢进症状消失，外周血细胞恢复正常。单纯肝切除组术后脾功能亢进症状加重，其中6例于术后3～7个月分别行脾动脉栓塞治疗。肝动脉栓塞化疗联合脾动脉栓塞组治疗后30 d 79％（34／43）的病例脾功能亢进症状改善，外周血细胞恢复正常。结论 原发性肝癌合并脾功能亢进的处理应争取行肝切除联合脾切除治疗，如肝癌不能切除，则应争取行肝动脉栓塞化疗联合脾动脉栓塞治疗。     

肝癌伴脾功能亢进的双介入治疗

目的评价联合应用肝动脉灌注化疗栓塞和部分性脾栓塞治疗肝癌伴脾功能亢进的临床价值及意义。方法收集肝癌伴脾亢58例,经导管肝动脉栓塞(TACE)同时行部分性脾栓塞(PSE),观察术前术后血细胞变化情况。结果TACE联合PSE治疗肝癌合并脾亢可明显改善患者外周血象,术后24小时、1周、2周及4周外周血白细胞、红细胞及血小板较栓塞前明显提高。结论对于肝癌合并脾功能亢进患者,在行肝动脉栓塞灌注化疗同时行部分性脾栓塞术,安全可靠,既能有效控制肿瘤发展,又能有效改善患者血象,提高机体免疫力和患者的生活质量。     

脾切除术与部分性脾栓塞术治疗肝硬化脾功能亢进的比较研究

目的对比研究脾切除术（包括开腹脾切除和腹腔镜下脾切除）与部分性脾栓塞术治疗肝硬化脾功能亢进的疗效。方法回顾分析我院1999年3月至2006年12月42例获得完整随访资料的行外科手术或介入处理的42例肝硬化脾功能亢进患者的临床资料，其中外科切除组19例，部分性脾栓塞组23例，比较观察两组术后第3、7、14、30天及1年的外周血象主要指标（RBC、WBC、PLT）、术后1个月及1年的NK细胞活性、术后住院时间、住院费用及并发症的发病率。结果两组患者术后不同时间的血细胞水平差异无统计学意义（P〉0．05），部分性脾栓塞组患者术后住院时间及住院费用明显低于外科手术组（P〈0．05），术后1个月及1年外科手术组NK细胞活性低于部分性脾栓塞组，差异具有统计学意义（P〈0．05）。结论外科脾切除与部分性脾栓塞治疗肝硬化脾功能亢进均有确切疗效，部分性栓塞在减少患者住院时间、降低住院费用及维持患者免疫功能方面更有优势，但治疗方案需个体化。     

脾动脉栓塞治疗肝癌伴肝硬化脾功能亢进20例体会

目的探讨脾动脉栓塞对原发性肝癌伴肝硬化脾功能亢进的治疗效果。方法采用常规的Seldinger法做脾动脉栓塞共20例,术前血小板计数1.9×10     

Splenic embolization in liver transplant recipients: early outcomes

Clinical improvement has been reported following splenic embolization for a wide variety of indications. Improvement following splenic embolization has been described in cirrhotic patients awaiting hepatic transplantation who are not candidates for surgical splenectomy. Occasionally, patients who have undergone hepatic transplantation have conditions that may also benefit from nonsurgical intervention with splenic embolization. Indications include persistent hypersplenism and pancytopenia precluding optimal treatment with antiviral therapy or chemotherapy, risk for persistent gastroesophageal variceal hemorrhage, and splenic artery steal syndrome attenuating hepatic arterial perfusion. Limited data is available on the outcome of splenic embolization in liver transplant recipients. We present the early outcomes of liver transplant recipients who were treated with splenic embolization. A retrospective chart review of all liver transplant recipients who underwent splenic embolization between 1997 and 2006 was performed, under minimal-risk study approval by the institutional review board. Five liver transplant recipients received splenic embolization: 3 for persistent hypersplenism, 1 for increased risk of gastroesophageal variceal hemorrhage, and 1 for splenic artery steal syndrome. The patients with hypersplenism demonstrated hematologic improvement, the patient with gastroesophageal varices did not experience any hemorrhage on follow-up, and the patient with splenic artery steal experienced resolution of the steal phenomenon. Postembolization syndrome was observed but no splenic abscess or death occurred. Mean follow-up was 20.2 months. In conclusion, splenic embolization is a safe and effective nonsurgical alternative for a variety of indications in liver transplant recipients.     

部分性脾动脉栓塞治疗脾功能亢进

目的探讨脾功能亢进行脾部分栓塞时对门脉压力及外周血液变化的影响。方法对36例脾功能亢进患者,采用Seldinger's法经皮脾动脉超选择性插管造影,计数直径>1mm的脾内动脉血管数。用明胶海绵碎屑(1mm×1mm×1mm)或PVA颗粒实行脾动脉栓塞,栓塞上述血管的60%～80%,并进行1～36个月(平均20个月)临床随访观察对比手术前后门脉压力、血液成分的变化。结果平均门脉压力由4.05kPa降至2.51kPa,外周血液红细胞由2.0×1012/L升至4.20×1012/L,白细胞从3.2×109/L升至5.0×109/L,血小板从40×109/L升至150×109/L。食管静脉曲张引发上消化道出血4例中,术后3例未再出血。结论栓塞程度以脾血管数为计数单位,控制在60%～80%时,可较好地改善脾功能亢进患者外周血象、门静脉压力,减轻食管静脉曲张程度。     

Evolving experience with prevention and treatment of splenic artery syndrome after orthotopic liver transplantation

Impaired hepatic arterial perfusion after orthotopic liver transplantation (OLT) may lead to ischemic biliary tract lesions and graft‐loss. Hampered hepatic arterial blood flow is observed in patients with hypersplenism, often described as arterial steal syndrome (ASS). However, arterial and portal perfusions are directly linked via the hepatic arterial buffer response (HABR). Recently, the term ‘splenic artery syndrome’ (SAS) was coined to describe the effect of portal hyperperfusion leading to diminished hepatic arterial blood flow. We retrospectively analyzed 650 transplantations in 585 patients. According to preoperative imaging, 78 patients underwent prophylactic intraoperative ligation of the splenic artery. In case of postoperative SAS, coil‐embolization of the splenic artery was performed. After exclusion of 14 2nd and 3rd retransplantations and 83 procedures with arterial interposition grafts, SAS was diagnosed in 28 of 553 transplantations (5.1%). Twenty‐six patients were treated with coil‐embolization, leading to improved liver function, but requiring postinterventional splenectomy in two patients. Additionally, two patients with SAS underwent splenectomy or retransplantation without preceding embolization. Prophylactic ligation could not prevent SAS entirely (n = 2), but resulted in a significantly lower rate of complications than postoperative coil‐embolization. We recommend prophylactic ligation of the splenic artery for patients at risk of developing SAS. Post‐transplant coil‐embolization of the splenic artery corrected hemodynamic changes of SAS, but was associated with a significant morbidity.     

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。     

Partial splenic ablation in preparation for renal transplantation in children

Patients with end-stage renal disease who develop hypersplenism, patients with mild neutropenia, and those patients whose WBC fails to increase in response to cortisol administration will develop significant neutropenia following transplantation with routine doses of azathioprine. This "intolerance" of azathioprine mandates a reduction in the dose of azathioprine often resulting in allograft rejection. Splenectomy will prevent azathioprine-induced neutropenia, but the hazards of splenectomy in these immunosuppressed patients have led to attempts to salvage at least part of the spleen. Partial splenic ablation by embolization has been utilized in adults prior to transplantation to prevent azathioprine-induced neutropenia while preserving the spleen's protective mechanisms against infection. Eight children in our series of transplant candidates required a reduction of splenic function to prevent azathioprine induced neutropenia. One child had a functioning renal allograft but had recurrent neutropenia limiting the azathioprine dose. Partial splenic embolization was attempted in four children and was initially successful in two. Both patients later developed recurrent neutropenia and needed partial splenectomy. The two patients in whom partial splenic embolization was unsuccessful and five further patients in whom embolization was not attempted also underwent partial splenectomy. Approximately 75% to 80% of the spleen was resected. Six children have since undergone renal transplantation and one child had a transplant with chronic rejection at the time of partial splenectomy. Routine doses of azathioprine have been used in these children with no episodes of neutropenia or sepsis observed. We recommend partial splenectomy in those children requiring renal transplantation who are at risk for development of azathioprine induced neutropenia.