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。     

断流术对门静脉高压症患者肝功能影响及止血效果的研究

目的观察门奇断流术对门静脉高压症患者肝功能的影响。方法回顾性分析40例门静脉高压症患者行贲门周围血管离断术的临床资料,分析术后肝功能变化、止血效果和再出血原因。结果全组患者手术后2周内肝功能不同程度改善。止血效果明显,急症止血率100%,择期手术止血率88.24%,远期再出血率11.76%,病死率5%。结论贲门周围血管离断术近期能改善肝功能、并止血,在治疗门脉高压肝硬化并上消化道出血的同时是一种较好治疗门静脉高压症的手术方式。     

脾腔分流加断流术治疗门静脉高压症上消化道出血

目的　观察脾腔分流加断流联合手术治疗门静脉高压症上消化道出血的疗效。方法　回顾性总结此术式治疗门静脉高压症上消化道出血56例的疗效。结果　手术死亡率为36%,术后近期无出血。远期再出血率41%。肝性脑病发生率为20%。术后1,3,5,10年生存率分别为981%,939%,825%,667%。结论　脾腔分流加断流术,既保留了断流术的优点,又降低了门静脉压力,特别对门静脉高压性胃病出血有较好疗效,并能保持一定量的门静脉向肝血流,有利于肝功能的恢复。     

分流断流联合术治疗食管曲张静脉破裂大出血（附186例报道）

目的　观察分流断流联合术 (脾肾分流加贲门周围血管离断术 )治疗食管曲张静脉破裂大出血的临床效果 ,探讨该术式的合理性。方法　采用分流断流联合术治疗门静脉高压症食管曲张静脉破裂大出血 186例。术中测定自由门静脉压力 ,运用超声彩色多普勒显像观察手术前后门静脉血流动力学变化 ,并对临床效果进行观察、随访。结果　手术死亡率 3 .2 %。术后近期无出血 ,远期再出血率为 8.2 %。术后肝性脑病发生率为 4 .8%。术后 1年、3年、5年、10年生存率分别为 98.1%、89 .9%、84 .3 %、67.9%。术后门静脉压力和门静脉、脾静脉的直径、流量、流速变化与术前相比有非常显著性差异 (P <0 .0 1)。结论　分流断流联合术具有止血效果确切 ,再出血率低 ,肝性脑病发生率低等优点 ,是治疗门静脉高压症食管曲张静脉破裂大出血合理而可行的术式。     

分流加断流联合术治疗门静脉高压症的疗效评价

目的评价分流和断流联合术（脾肾分流加贲门周围血管离断联合术）治疗门静脉高压症的临床疗效及门静脉系血流动力学的变化。方法回顾分析1980—2005年入院的400例门静脉高压症患者分别施行分断流联合术（300例）和断流术（100例）的临床资料,并对部分患者手术前后行彩色多普勒显像、数字减影血管造影检查和术中自由门静脉压力测量。结果本组分断流联合术再出血率为5.9%,术后肝性脑病发生率为5.1%,术后1、3、5、10和15年生存率分别为94.9％、91.9%、84.9%、69.2%和45.1%。断流术后近期出血率为5.5%,远期再出血率为21.6%,肝性脑病发生率为4.5%。分断流联合术组术后自由门静脉压为（30.5±2.6）cm H2O,门静脉血流量为908 ml/min,均较术前降低,差异有统计学意义（P＜0.01）,并较断流术组显著降低和减少（P＜0.05）,但联合术与断流术后的门静脉血流量减少相比差异无统计学意义（P＞0.05）,联合术后门静脉头向侧支消失。结论从临床效果和血流动力学证实分断流联合术是一种治疗门静脉高压症合理而实用的术式。     

断流术联合胃底切除治疗门静脉高压症

目的 探讨断流术加食管下端及胃底切除术治疗门静脉高压的疗效.方法 回顾性分析32例采用断流术联合食管下端及胃底切除术治疗门静脉高压症患者(联合组)的临床资料,并以34例贲门周围血管离断术为对照组,患者均为肝炎后肝硬化,均患有明显的食管胃底静脉曲张,且有1次以上出血史.结果 患者均获随访,平均14个月,两组患者术后门静脉压变化及手术近期病死率比较,差异无统计学意义(P>0.05);食管胃底静脉曲张、术后再出血、腹胀和早期胃潴留等联合组明显优于断流组(P<0.05).结论 断流术联合胃底切除治疗门静脉高压症上消化道出血止血确切,复发出血率低,并发症少,是治疗门静脉高压症较理想的一种手术方法.     

门静脉高压症术后再出血的外科治疗

目的 评价外科治疗门静脉高压症术后再出血各种术式的疗效。方法 回顾30年外科治疗门静脉高压373例中术后再出血66斧正临床资料。其中首次手术方式分别有单纯脾切除术、门奇静脉断流术、各类非选择性分流术、联合手术（断流加分流）,术后再出血率分别为26.67%、17.86%、14.58%和4.35%,再手术组55例中食管下段胃底切除42例,肠系膜上静脉-下腔静脉分流（MCS）11例,再断流2例,非手术组11例。结果 食管下段胃底切除组手术死亡率9.52%(4/42),随访平均11年,再出血率9.52%(4.42),脑病发生率14.29%(6/42);再断流组2例术后1个月内死亡;MCS组11例无手术死亡,随访平均7.5年,无再出血,脑病发生率9.09%（1/11）;非手术组11例均为门静脉高压性胃病（PHG）。结论 联合手术能有效减少门静脉高压术后再出血,MCS是目前治疗再出血较理想的手术方式。     

分流加断流联合手术治疗门静脉高压症

目的　探索分流加断流联合手术(联合术)治疗门静脉高压症的疗效。方法　通过对手术前后门静脉系血流动力学研究和前瞻性临床研究,对联合术治疗的150例门静脉高压症的临床资料进行分析。结果　联合术后近期无1例出血,远期再出血率为80%,术后肝性脑病发生率为48%,远期效果理想。血流动力学研究证明了本联合术的合理性。结论　脾肾分流加门奇断流联合术是治疗门静脉高压症的一种合理而可取的术式。     

联合断流治疗门静脉高压症

目的 总结联合断流术治疗门静脉高压症的疗效。方法 分析联合断流术52例,均为肝炎后肝硬化。结果急诊手术全部止血无死亡,术后大量腹水2例,隔下感染1例。平均随访3.6年,术后出血率为0(5年)和5.8％(9年)。随访生存率96％(5年)和90％(9年)。无肝性脑病和肝功能衰竭发生。结论 联合断流术适应证广,术式易掌握,疗效满意,但应注意断流的彻底性、围手术期的处理及术后的长期治疗。     

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     

Hepatic resection in 120 patients with hepatocellular carcinoma

During the 11-year period from 1977 through 1987, hepatic resections were carried out in 120 patients with hepatocellular carcinoma (HCC). Twenty-five had HCCs smaller than 5 cm in diameter. There were 97 male and 23 female patients, with an average age of 51.5 years. Among them, 45.8% had liver cirrhosis and 80.8% were positive for hepatitis B surface antigen. Fourteen with ruptured HCCs underwent hepatic resection to control the intra-abdominal hemorrhage. Operative mortality within one month after surgery was 4.1%. The postoperative course was complicated by pleural effusion in 5.8%, subphrenic abscess in 2.5%, postoperative bleeding in 1.6%, hepatic failure in 1.6%, and bile leakage in 0.8% of the patients. The overall five-year survival rate in this series was 25.9%, while survival for the last five years was better (42.3% vs 11.9% for patients treated between 1977 and 1982). The cumulative survival rate had no relation to tumor rupture or liver cirrhosis. The group of patients with smaller tumors (diameter, less than 5 cm) or without vascular invasion by tumor had better survival.     

Clinical experience with 118 hepatic resections for hepatocellular carcinoma

During the recent 5 2/3 years, hepatic resection was performed on 118 patients with hepatocellular carcinoma. Ages ranged from 17 to 78 years with an average of 57 years. There were 101 males and 17 females. Underlying cirrhosis of the liver was found in 101 cases, and chronic hepatitis was found in 16 cases. Before surgery 62 patients had 71 associated conditions such as esophageal varices, diabetes mellitus, cholelithiasis, or peptic ulcer. Operations for the varices and cholelithiasis were performed simultaneously with hepatic resection in 15 and six patients, respectively. The operative mortality rate within 1 month was 7.6%, and the overall in-hospital death rate was 14.4%. In 94 patients with curative resection, the 2-year survival rate was 81.2% in patients without cirrhosis and 55.4% in patients with cirrhosis. The 4-year survival rate was 81.2% in the former and 34.8% in the latter group. The prognosis was significantly better in patients without cirrhosis than in those with cirrhosis. On the contrary, 21 of 24 patients with palliative resection died within 2 years despite extensive chemotherapy. The present results may indicate that the resectability rate of hepatocellular carcinoma is currently increasing, even in the presence of cirrhosis of the liver due to early detection of the tumor by current advances in diagnostic methods and also that major hepatic resection is possible in selected patients with cirrhosis.     

507 Warren-Zeppa distal splenorenal shunts: a 34-year experience

OBJECTIVE: To define the long-term characteristics, prognostic factors, and outcomes of patients undergoing selective splenorenal shunting procedures for portal hypertension-induced recurrent upper gastrointestinal bleeding. MATERIALS AND METHODS: A retrospective evaluation of a prospectively collected data set. RESULTS: From June 1971 through May 2005, 507 Warren-Zeppa shunts were performed at a single institution. Indications included: alcoholic cirrhosis, 52.6%; viral cirrhosis, 21.8%; cryptogenic cirrhosis, 8.4%; autoimmune cirrhosis, 5.8%; and other causes, 6.3%. Median survival was 81 months (5-year survival, 58.9%; 10-year survival, 34.4%; 20-year survival, 12.5%). patients with portal vein thrombosis and biliary cirrhosis demonstrated better survival than others (P = 0.03), while patients with alcoholic cirrhosis trended toward worse survival than those with nonalcoholic causes (P = 0.11). Multivariate analysis of preoperative risk factors found body hair loss (hazard ratio, 17.3; P > 0.005), preoperative encephalopathy (hazard ratio, 1.93; P > 0.003), diuretic use (hazard ratio, 1.43; P > 0.003), and age (hazard ratio, 1.02 per year of age; P > 0.051) were independent predictors of poor long-term survival. Multivariate analysis of operative factors demonstrated blood loss <500 mL was predictive of up to a 4-fold improved long-term survival (hazard ratio, 3.95; P < 0.013). Postoperative complications included: recurrent bleeding, 12%; ascites, 17.5%; and encephalopathy, 13.9%. Multivariate analysis of postoperative factors prospectively collected in 130 patients found that alcoholic recidivism (hazard ratio, 2.66; P > 0.001) was the only independent predictor of poor prognosis. CONCLUSIONS: The Warren-Zeppa shunt provides long-term survival and control of bleeding in most patients with portal hypertension. Excellent long-term survival can be obtained in properly selected patients with portal hypertension and relatively spared hepatic function.     

Cryosurgery for primary hepatic cancer of 87 patients]

From november 1973 to June 1991, cryosurgery with liquid nitrogen was performed on 87 patients with primary liver cancer (PLC). Of these, 27 patients was of stage I (31.0%), 52 in stage II (59.8%), and 8 stage III (9.2%). There were 30 patients with PLC of < or = 5 cm (34.5%). Liver cirrhosis was found in 73 patients (83.9%). In the beginning, plate-like cryoprobes and thermocouples were used to monitor the frozen area. Later on we designed single- and multiple-needle cryoprobes for freezing tumors deeply into the hepatic parenchyma and intraoperative ultrasound was used to monitor hepatic cryolesions. The 1-year, 3-year, and 5-year survival rates were 60.5%, 32.0%, and 20.2%, respectively. Among the 30 patients with PLC of < or = 5 cm, the 1-year, 3-year, and 5-year survival rates were 92.6%, 66.6%, and 50.8%, respectively. There were no operative mortality and complications such as rupture of the tumor, delayed bleeding, and bile leakage. These results indicate that cryosurgery is a safe and effective local treatment for unresectable PLC.     

Long-term results of the Hassab operation in portal hypertension: 10 year's follow-up

Seventy-three patients with portal hypertension who underwent Hassab operation before June 30, 1976 and were alive postoperatively were analysed. Among these patients, portal hypertension was caused by hepatic schistosomiasis in fifty-seven, and by portal cirrhosis in seventeen. According to Child's classification there were 14 in class A, 19 in class B, 30 in class C, and 10 were not classified. Thirty-two patients were subjected to therapeutic operation, forty-one to prophylactic operation. Seventy-one patients were followed-up (97.3%). The postoperative 5, 10 and 15 year cumulative survival rate were 85.5%, 75.8%, and 70.4% respectively. The survival rates in Child A, B patients were much higher than that in Child C patients (P less than 0.05). The postoperative bleeding rate was 11.3%, and the bleeding most often occurred in 1-9 year postoperatively. The esophageal varices disappeared in 64.3% of patients; ascites disappeared in 91.7% of patients; liver function improving or unchanging was seen in 93.6% of patients. There was no postoperative encephalopathy. Long term follow-up showed no difference in patient's survival rate between hepatic schistosomiasis and portal cirrhosis.     

急诊手术治疗门静脉高压症并上消化道大出血手术疗效评价

目的探讨急诊手术在治疗门静脉高压症并上消化道大出血中的效果和意义。方法对我院近5年内151例门静脉高压症并上消化道大出血患者行急诊手术的疗效和并发症发生率进行回顾性研究,其中肝功能ChildA级72例,B级58例,C级21例。结果总体出血有效控制率95.3%,断流术死亡率为7.7%(10/130),死亡的主要原因为腹腔内出血、上消化道出血和肝肾综合征,分流术死亡率为38.1%(8/21),死亡的主要原因为肝肾功能衰竭。术后1年生存率为97.7%,3年生存率为94.2%,5年生存率为86.8%。术后1年再出血率为1.5%(2/133),3年再出血率为5.7%(4/70),5年再出血率为7.9%。结论在当今条件下贲门周围血管离断术仍是挽救门静脉高压症并发不可内科控制的上消化道大出血患者生命的主要急诊手段,肝内型门静脉高压急诊手术最好不选择分流手术。     

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。     

Long-term results of hepatic resection for hepatocellular carcinoma originating from the noncirrhotic liver

HYPOTHESIS: In patients with hepatocellular carcinoma who do not have cirrhosis, the clinicopathologic characteristics and long-term postresectional outcomes must be clarified and liver transplantation may also have a role in future treatment strategy. DESIGN: Case series. The mean (SD) follow-up time was 52.4 (33.8) months. SETTING: A tertiary care medical center. PATIENTS: From a prospective database, 445 patients with hepatocellular carcinoma who underwent hepatectomy were classified into 2 groups-those without cirrhosis (n = 223) and those with cirrhosis (n = 222). Clinicopathologic factors and postresectional outcomes were compared between these groups based on the new American Joint Committee on Cancer/Union Internationale Contre le Cancer TNM (sixth edition) staging system and the patient selection criteria for undergoing transplantation. MAIN OUTCOME MEASURES: Postresectional disease-free and overall survival rates. RESULTS: Compared with patients with cirrhosis, patients without cirrhosis were younger, had a lower rate of viral hepatitis type C infection, and had more advanced TNM stage III disease. Also more of the patients who did not have cirrhosis had undergone major resection. The tumor recurrence rate was significantly lower in the noncirrhotic group than in the cirrhotic group (59.5% vs 69.5%, P =.03). The 5- and 10-year disease-free and overall survival rates of the noncirrhotic group were 36.8% and 25.7%, and 53.0% and 36.9%, respectively. The survival of the members of the noncirrhotic group was better than the survival of the members of the cirrhotic group for patients with early stage (TNM stage I or transplantable) diseases. The 5-year disease-free and overall survival rates in patients without cirrhosis with transplantable diseases were 54.8% and 70.0%, respectively. CONCLUSIONS: In early stage diseases, patients without cirrhosis had significantly better survival rates than patients with cirrhosis. For a small hepatocellular carcinoma originating in a noncirrhotic liver, hepatic resection is a reasonable first-line treatment. Liver transplantation can be reserved as salvage treatment for patients with recurrent disease after hepatic resection.     

Survival after hepatic resection for malignant tumours.

A retrospective analysis of 194 patients who underwent hepatic resection for primary or metastatic malignant disease from January 1962 to December 1988 was undertaken to determine variables that might aid the selection of patients for hepatic resection. Hepatic metastases were the indication for resection in 126 patients. The 5-year survival rate was 17 per cent. For patients with resected metastases from colorectal cancer (n = 104), the survival rate at 5 years was 18 per cent. The 5-year survival rate was 27 per cent when the resection margin was > 5 mm compared with 9 per cent when the margin was < or = 5 mm (P < 0.01). No patient with extrahepatic invasion, lymphatic spread, involvement of the resection margin or gross residual disease survived to 5 years, compared with a 23 per cent 5-year survival rate for patients undergoing curative resection (P < 0.02). The survival rate of patients with poorly differentiated primary tumours was nil at 3 years compared with a 20 per cent 5-year survival rate for patients with well or moderately differentiated tumours (P not significant). The site and Dukes' classification of the primary tumour, the sex and preoperative carcinoembryonic antigen level of the patient, and the number and size of hepatic metastases did not affect the prognosis. The 5-year survival rate for patients with hepatocellular carcinoma (n = 42) was 25 per cent. An improved survival rate was found for patients whose alpha-fetoprotein level was normal (37 per cent at 5 years) compared with those having a raised level (nil at 3 years) (P < 0.01). Involvement of the resection margin, extrahepatic spread and spread to regional lymph nodes were associated with an 8 per cent 5-year survival rate versus 44 per cent for curative resection (P < 0.005). The presence of cirrhosis, the presence of symptoms, and the multiplicity and size of the tumour did not affect the prognosis. The 5-year survival rate of 11 patients with hepatic sarcoma was 25 per cent. No patient with peripheral cholangiocarcinoma survived to 1 year in contrast to patients with hilar cholangiocarcinoma, all four of whom survived for more than 14 months.