经皮经肝胃冠状静脉栓塞术联合脾动脉栓塞术治疗肝硬化食管胃底静脉曲张疗效观察

目的 观察经皮经肝胃冠状静脉栓塞术联合脾动脉栓塞术治疗肝硬化食管胃底静脉曲张的疗效.方法 12例经胃镜明确为食管胃底重度静脉曲张出血的肝硬化患者,择期行经皮经肝胃冠状静脉栓塞术及脾动脉栓塞术,术后定期胃镜检查,观察曲张静脉的动态变化.结果 术后即时食管胃底曲张静脉均消失;随访6～12个月曲张静脉基本消失6例,中度曲张3例,仍为重度曲张者3例,其中2例发生再出血,行胃镜下硬化剂治疗.结论 经皮经肝胃冠状静脉栓塞术联合脾动脉栓塞术是治疗肝硬化食管胃底静脉曲张安全有效的方法.     

Glubran-2胶栓塞术治疗门静脉高压食管胃底静脉曲张

目的观察Glubran-2胶栓塞术治疗门静脉高压食管胃底静脉曲张的疗效。方法中重度门静脉高压食管胃底静脉曲张患者15例,经皮经肝穿刺门静脉造影明确出血曲张静脉后,超选择插管行Glubran-2胶栓塞术治疗。栓塞前后进行CT平扫联合增强扫描,并测定患者门静脉压力。结果 15例患者成功进行胃左静脉、胃后静脉和胃短静脉Glubran-2胶完全性栓塞术。门静脉压力术前为(34.1±7.1)cmH2O、术后为(37.7±4.1)cmH2O,手术前后相比,P<0.05。术后CT增强扫描显示曲张静脉完全栓塞,其内可见高密度铸型。术后随访3～12个月,再出血2例。结论 Glubran-2胶栓塞术治疗门静脉高压食管胃底静脉曲张安全有效,手术前后CT检查可明确诊断及判断疗效。     

联合导向下经皮经肝胃冠状静脉栓塞治疗食管胃底静脉曲张出血

目的 评价经皮经肝胃冠状静脉栓塞术在治疗肝硬化患者食管、胃底静脉曲张破裂出血中的应用价值。方法 对l8例肝硬化合并食管、胃底静脉曲张破裂出血患者，其中8例患者大出血中急诊栓塞，l0例患者出血后择期栓塞。在B超和X线联合导向下，经皮经肝穿刺门静脉。所有患者在B超引导下门静脉穿刺一次成功，行门静脉造影和胃冠状静脉造影及栓塞。结果 l7例患者胃冠状静脉栓塞成功，其中l例栓塞后6h再次出血，行经颈静脉肝内门体分流手术，血止。急诊止血率87．5％，栓塞成功率94．4％。l～24个月随访期内，再出血4例，肝功衰竭2例，肝癌2例，共死亡6例，l2例存活。结论 对于肝硬化食管、胃底静脉曲张破裂出血患者，经B超和X线联合导向下，经皮经肝胃冠状静脉栓塞术是一种安全、有效的止血方法。     

肝硬化门脉高压上消化道出血的防治 胃冠状静脉栓塞治疗

胃冠状静脉栓塞术 (又称食管胃底曲张静脉栓塞术 )是治疗肝硬化门脉高压胃食管曲张静脉破裂出血的有效方法。但该疗法不能降低门脉压力甚至使门脉压力升高 ,在预防远期再出血方面疗效不满意 ,因此常联合部分脾动脉栓塞术或经颈静脉肝内门体分流术 (TIPSS)。1　适应证和禁忌证适应证 :食管胃冠状静脉栓塞术主要用于临床保守治疗或内镜下治疗无效的食管胃底静脉曲张破裂出血 ,治疗主要在出血期进行。禁忌证 :有明显出血倾向者或终末期患者。2　操作方法直接门静脉造影 ,显示胃冠状静脉和 (或 )胃短静脉以及增粗扭曲的食管胃底静脉丛 ,借助导…     

经皮胃冠状静脉栓塞术联合脾动脉主干截流术治疗肝硬化盗血综合征临床研究*

目的观察经皮胃冠状静脉栓塞术联合脾动脉主干截流术治疗肝硬化盗血综合征患者的疗效。方法在89例肝硬化并发脾功能亢进症伴食管胃底静脉曲张破裂出血患者中,53例接受经皮胃冠状静脉栓塞术联合脾动脉主干截流术治疗,36例行脾动脉主干截流术治疗。在术后1个月、6个月、12个月观察肝功能、血常规等指标变化及再出血和生存情况。结果术后1个月、6个月、12个月联合组再出血率分别为0.0%、5.7%和15.1%,而脾动脉主干截流术治疗患者分别为0.0%、16.7%（P<0.05）和44.4%（P<0.05）;术后两组白细胞和血小板计数均升高,但在6个月后又有所下降,两组生存患者 Child-Pugh评分无显著相差（P>0.05）。结论采用经皮胃冠状静脉栓塞术联合脾动脉主干截流术治疗肝硬化并发食管胃底静脉曲张破裂出血患者损伤小、安全性好,控制再出血作用肯定。     

食管胃底曲张静脉栓塞联合部分脾动脉栓塞术

食管胃底曲张静脉破裂出血是肝硬化门静脉高压患者上消化道大出血的主要原因,经皮经肝曲张血管栓塞术(PTVE)和部分脾动脉栓塞术(PSE)是近年来应用于肝硬化门脉高压症介入治疗的新技术。1适应证和禁忌证适应证:食管胃冠状静脉栓塞术主要用于临床保守治疗或内镜下治疗无效的食管胃底静脉破裂出血,治疗主要在出血期进行。禁忌证:有明显出血倾向者或终末期患者。2操作方法直接门静脉造影,显示胃冠状静脉和(或)胃短静脉以及增粗扭曲的食管胃底静脉丛,借助导管导丝进入胃冠状静脉及胃短静脉进行栓塞治疗。先用无水乙醇5～30ml分次推注,再用高压…     

经皮经肝胃冠状静脉栓塞联合部分脾动脉栓塞术治疗门静脉高压症的临床研究

胃冠状静脉栓塞术(PTO)是治疗肝硬化食管胃底静脉曲张的有效介入手术.单纯行PTO术可有效达到止血目的,但不能解决门静脉高压,其远期效果不理想.单纯行部分脾动脉栓塞术(PSAE)可降低门静脉压力,缓解脾功能亢进,但不能控制急性出血.在PTO术基础上联合PSAE术,可控制急性出血,降低门静脉压力,同时缓解脾功能亢进.     

经皮经肝组织黏合剂栓塞联合部分脾栓塞治疗食管静脉曲张

目的评价经皮经肝穿刺组织黏合剂（TH胶,α-氰基丙烯酸正丁酯）栓塞联合部分脾动脉栓塞（PSE）治疗食管静脉曲张的临床疗效。方法以食管下段曲张静脉和贲门胃底周围血管为靶血管,将TH胶灌注至食管下段及胃底曲张静脉内,使曲张静脉永久性闭塞,并联合PSE治疗食管静脉曲张出血患者84例,18例患者行急诊栓塞治疗。结果（1）81例栓塞成功,成功率96.4%,3例术后1个月因肝功能衰竭、腹腔感染和脑出血死亡。（2）TH胶栓塞到食管下段曲张静脉及胃底周围血管者38例;栓塞冠状静脉及胃底贲门周围曲张静脉但未达食管下段者31例;仅栓塞到胃冠状静脉主干者9例。术后其食管静脉曲张消失率分别为71.1%（27/38）、35.5%（11/31）、0（0/9）,χ^2=18.3105,P〈0.01。（3）随访6～47（31.0±16.5）月,13例患者再出血,总出血率为16.7%。其中食管胃底型栓塞再出血率为7.9%（3/38）;胃底型再出血率为12.9%（4/31）;主干型再出血率为66.7%（6/9）,χ^2值分别为12.6603和8.0765;P值均〈0.01。结论经皮经肝TH栓塞联合部分脾动脉栓塞不仅可控制急症出血,还可预防再出血,是治疗和预防门静脉高压食管静脉曲张出血的有效方法,术中应尽量将TH胶注射到食管下段曲张静脉和贲门胃底周围静脉内,以确保介入栓塞治疗的远期疗效。     

经皮经肝胃冠状静脉栓塞术的临床疗效观察

目的观察经皮经肝胃冠状静脉栓塞术（PTVE）的临床疗效。方法经皮经肝胃冠状静脉栓塞术治疗肝硬化食管胃底静脉曲张患者58例,26例联合部分脾栓塞术（PSE）;42例进行了一年随访。结果门静脉穿刺插管成功率96.55%。急诊PTVE止血15例,止血率100%。随访期8例患者再次出血。3例大出血;5例少量出血。12月随访时,食管、胃底静脉曲张减轻、消失35例（35/42）。结论PTVE创伤小,止血效果肯定,可作为肝硬化食管胃底静脉曲张出血的首选治疗方法。     

经皮经肝α-氰基丙烯酸正丁酯胶和生物蛋白胶联合栓塞治疗食管胃底静脉曲张20例

目的介绍经皮经肝α-氰基丙烯酸正丁酯(NBCA胶,n-butyl-2-cyanoacrylate)和生物蛋白胶联合栓塞食管胃底静脉曲张的应用。方法采用经皮经肝NBCA胶和生物蛋白胶联合栓塞胃冠状静脉和胃短静脉为主的方法治疗门静脉高压食管胃底静脉曲张患者20例,生物蛋白胶以栓塞胃部曲张静脉的流出端为主,NBCA胶栓塞胃部曲张静脉的主体和输入段,部分加用弹簧圈栓塞减慢血流。15例患者同时行部分性脾动脉栓塞。结果栓塞成功16例(80%),术后即刻食管胃底曲张静脉血流消失而且出血控制。随访1~11个月(平均4.3个月),成功栓塞的16例患者无1例发生再出血,其中胃镜复查11例,5例曲张静脉基本消失,4例明显减轻,2例稍有减轻。4例患者曲张静脉内NBCA充填不充分,致使栓塞不彻底,其中2例发生再出血。无1患者发生异位栓塞和胃黏膜的过度栓塞。结论经皮经肝NBCA胶和生物蛋白胶联合栓塞食管胃底静脉曲张可有效防止异位栓塞及过度栓塞,安全而且疗效确切,可作为治疗食管胃底静脉曲张破裂急性出血的重要治疗手段之一。能否彻底栓塞是决定疗效的主要因素。     

Combination treatment of partial splenic embolization, endoscopic embolization and transjugular retrograde obliteration for complicated gastroesophageal varices

The treatment of complicated gastroesophageal varices with a gastrorenal shunt and portal hypertensive gastropathy has not yet been established. We were able to control a case of complicated large gastroesophageal varices with gastrorenal shunt and portal hypertensive gastropathy using a combination treatment of partial splenic embolization, endoscopic embolization and transjugular retrograde obliteration. We first applied partial splenic embolization to reduce the hyperdynamic cycle of portal hypertension and to treat thrombocytopenia. We secondarily applied endoscopic embolization for the esophageal varices. Transjugular retrograde obliteration was performed for the gastric varices 14 days after endoscopic embolization. The wedged hepatic venous pressure had not changed after transjugular retrograde obliteration. After the combination treatment, the gastroesophageal varices were successfully obliterated, but portal hypertensive gastropathy did not worsen. The platelets count, arterial ketone body ratio and ICGR15 were improved. Partial splenic embolization was useful to protect side effects of endoscopic embolization and transjugular retrograde obliteration. We conclude that the combination treatment of partial splenic embolization, endoscopic embolization and transjugular retrograde obliteration is a rational, effective and safe treatment for complicated gastroesophageal varices with gastrorenal shunt and portal hypertensive gastropathy.     

部分脾栓塞联合心得安预防食管胃底静脉曲张再出血的研究

[目的]评价部分脾动脉栓塞术（PSE）联合心得安预防食管胃底静脉曲张再出血的临床疗效.[方法]55例食管胃底静脉曲张破裂出血患者,随机分为两组,其中心得安组28例,PSE联合心得安组27例,比较两组患者外周血象变化,门静脉、脾静脉管径变化,以及3个月、6个月、1年、2年不同时间段的再出血率、病死率和并发症情况.[结果]术后1个月PSE联合心得安组较心得安组外周血白细胞及血小板显著升高,门静脉及脾静脉管径明显缩小,再出血率降低,差异有统计学意义（P＜0.05）.[结论] PSE联合心得安预防食管胃底静脉曲张再出血较单独使用心得安有更好的疗效.     

Control of isolated gastric varices by combination therapy using embolization and endoscopic scleroligation therapy

Balloon-occluded retrograde venous obliteration is a powerful new technique for eliminating gastric varices. However anatomic considerations may preclude its use in some instances. Two cases are reported in which combination embolization followed by endoscopic injection scleroligation therapy eradicated isolated gastric varices where balloon-occluded retrograde venous obliteration was impossible. Two men with alcoholic cirrhosis were admitted with bleeding gastric varices. Inability to access variceal venous drainage precluded balloon-occluded retrograde venous obliteration. In Case 1, transileocolic vein obliteration left gastric embolization, and partial splenic embolization only partially eradicated gastric varices. In Case 2, percutaneous transhepatic obliteration, left gastric embolization, and partial splenic embolization were only partially successful. In both cases, endoscopic injection scleroligation therapy was performed adjunctively. Endoscopic injection scleroligation therapy completely eradicated gastric varices in both patients following partially successful embolization therapy. These cases demonstrate the importance of individualizing treatment of esophageal varices, the value of combination therapy, and the effectiveness of endoscopic injection scleroligation therapy for treating varices.     

门静脉高压症栓塞治疗前、后门静脉压力变化及其临床意义

目的:观察门静脉高压症(PHT)出血患者食管胃底静脉丛应用α-氰基丙烯酸烷基酯(TH胶)栓塞前、后门静脉系统压力动态变化,分析其与消化道出血的关系及预测再出血风险.方法:35例食管胃底静脉曲张破裂出血患者,其中25例行食管胃底静脉丛TH胶栓塞,10例行食管胃底静脉丛TH胶栓塞+部分脾动脉栓塞(PSE).比较术前、术后门静脉主干、肠系膜上静脉、脾静脉压力变化;观察患者术前、术后肝功能变化;观察手术并发症并对患者进行术后随访3～18个月.结果:35例患者均成功止血.食管胃底静脉丛栓塞术后门静脉主干静脉压为(37.45±5.11)am H2O(1 cm H2O=0.098 kPa),较术前明显升高[(32.54±5.23)cm H2O,P<0.01];术后肠系膜上静脉压为(34.33±4.68)cm H2O,较术前升高[(31.46±4.35)am H2O,P<0.053.10例经食管胃底静脉丛栓塞+PSE治疗后,患者门静脉主干、肠系膜上静脉和脾静脉压力均较术前明显降低[分别为(28.70±4.58)cm H2O比(32.68±4.89)cm H2O、(28.03±4.12)cm H2O比(31.46±4.35)cm H2O和(28.81±5.12)cm H2O比(32.89±4.79)cm H2O P值均<0.053.食管胃底静脉丛栓塞术后3周患者血清白蛋白为(34.57±6.84)g/L,较栓塞前高[(30.45±5.78)g/L,P<0.05].术后少量患者出现发热、腹水,经对症治疗后好转.治疗3个月后胃镜显示食管静脉曲张明显减轻.结论:食管胃底曲张静脉栓塞对食管胃底静脉曲张急症出血治疗有效,且对肝细胞功能恢复有一定效果,但有增加消化道再出血风险.食管胃底曲张静脉栓塞+PSE对降低门脉压力及治疗食管胃底静脉曲张出血有效,但不利于肝细胞功能恢复,有增加腹水的风险.     

TH胶栓塞联合门体静脉小分流治疗肝硬化门脉高压食管胃底静脉曲张出血

目的探讨应用TH胶栓塞联合门体静脉小分流治疗门脉高压食管胃底曲张静脉曲张破裂出血中的应用价值。方法入选41例门静脉高压症并食管胃底静脉曲张的患者,其中21例行TH胶栓塞联合门体静脉小分流术（A组）,另外20例患者行经皮经肝食管胃底曲张静脉栓塞术（PTVE）联合部分性脾栓塞（PSE）（B组）,对比两组患者肝功能、白细胞、血小板改变、食管胃底曲张静脉消失率、再出血率、肝性脑病发生率及门静脉自由压（free portal pressure,FPP）变化。结果 A组曲张静脉消失率、总有效率均高于B组（P〈0.05）,再出血率、肝性脑病发生率均低于B组（P〈0.05）,术后门静脉压力亦明显低于B组（P〈0.01）。两组术后白细胞及血小板、白蛋白较术前明显升高,差异有统计学意义（P〈0.01）,两组之间也存在显著统计学差异（P〈0.01）。结论以TH胶栓塞联合门体静脉小分流治疗门静脉高压症食管胃底静脉曲张安全、有效、并发症少,值得临床应用与推广。     

Splenogastrorenal shunt in portal hypertension: a little known entity. Study of 6 cases and review of the literature

The authors report 6 cases of portal hypertension with gastrorenal shunt. This shunt did not arise from the left gastric vein, but from the splenic vein. Portal hypertension was related to alcoholic cirrhosis in 3 cases, to extensive portal thrombosis in 2 cases, and to nodular regenerative hyperplasia of the liver in one case. A gastrointestinal hemorrhage revealed portal hypertension and the liver disease in the 3 cases of alcoholic cirrhosis and complicated the course of the disease in the other cases. Hemorrhage was either massive and life-threatening or often recurred. It was related to a rupture of fundic varices in all cases. The fundic varices were not associated with esophageal varices in the 3 cases of cirrhosis. The degree of portal hypertension was above 20 mm Hg, as assessed by the portohepatic gradient (one case), or the pressure gradient between a tributary portal system vein and the inferior vena cava during laparotomy (5 cases). Definitive control of hemorrhage could not be achieved by endoscopic variceal sclerotherapy (2 cases) or percutaneous transhepatic embolization (one case). Portacaval shunt or splenectomy was performed in 5 cases. These findings suggest that spontaneous splenogastrorenal shunt is a clinical and hemodynamic entity which requires specific treatment when associated with gastric variceal bleeding.     

Splenic artery embolization for variceal hemorrhage following blocked distal splenorenal shunt

A blocked distal splenorenal shunt presents with torrential bleeding from gastric varices. Reoperation in the presence of portal hypertension in an unstable patient is difficult. Two patients with a blocked distal splenorenal shunt were subjected to splenic artery embolization. This stopped variceal bleeding from gastric varices resulting from the congested spleen due to thrombosis of the splenic vein. The procedure was successful in stopping the acute bleed in both patients. There were no serious complications or recurrent variceal bleeding and the varices were collapsed at one year on follow-up endoscopy. Splenic artery embolization is a safe and effective minimally invasive treatment for patients with bleeding from a blocked distal splenorenal shunt.