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。     

部分性脾动脉栓塞方法的探讨

对11例脾功能亢进患者作部分性脾动脉栓塞治疗.5例应用明胶海绵栓塞,6例应用褐藻胶微球行脾下极动脉超选择插管栓塞.治疗后,全部病例均有效控制了脾功能亢进所致血小板减少和出血倾向,脾下极动脉微球栓塞的优点:1.脾下极栓塞不会引起左侧膈肌和胸膜刺激症状;2.大网膜向梗死的脾下极游走包裹可减轻和限制反应性炎症.使术后疼痛等继发症状明显减轻;3.可准确控制栓塞面积;4.微球栓塞在小动脉远端,不易形成侧支循环或再通;5.避免了误栓胰腺动脉的可能性.     

部分脾脏栓塞术治疗肝硬化门脉高压合并脾机能亢进的临床研究

目的 :探讨部分脾脏栓塞术对肝硬化门脉高压合并脾机能亢进的治疗价值。方法 :应用PVA颗粒 ,对 4 6例门脉高压肝硬化合并脾脏机能亢进的患者施行经脾动脉部分脾脏栓塞术 ,随访术后不同时间窗内疗效并对比研究了栓塞前后的门静脉和脾静脉血流速度的变化。结果 :4 6例患者成功施行了经脾动脉栓塞技术 ,达到了临床预期的治疗目标 ,消除了脾机能亢进的症状 ,无严重并发症发生 ,白细胞和血小板术后 2 4h即有明显改善 (P <0 .0 5 ) ,4周后恢复正常水平保持平稳。脾静脉和门静脉血流速度手术后明显降低 (P <0 .0 5 ) ,随访 6～ 2 1个月 ,脾机能亢进的症状未复发。结论 :部分脾脏栓塞术简便微创安全 ,治疗肝硬化门静脉高压合并脾机能亢进疗效好 ,值得临床推广应用。     

肝癌合并门脉高压脾功能亢进11例外科治疗

目的 探讨肝癌合并门静脉高压脾功能亢进患者外科治疗的方法。方法 回顾分析2001～2002年经手术治疗的肝癌合并门脉高压脾功能亢进患者11例，切除肝癌病灶同时行脾切除，或加行贲门周围血管离断术。结果 全组无手术死亡。术后并发症有腹水、低钠血症、上消化道出血、腹腔内出血。结论 肝癌合并门静脉高压脾功能亢进一期进行手术治疗是安全可行的。     

部分脾栓塞治疗肝癌伴脾功能亢进26例分析

目的 探讨对原发性肝癌伴脾功能亢进（脾亢）患者行部分脾栓塞的临床价值。方法对26例不能行手术切除,且血细胞明显低于正常的原发肝癌伴脾亢患者行部分脾栓塞,栓塞面积控制在50%～70%,栓塞前后测定血细胞数量,并作统计学分析。结果脾栓塞术后24、48、72h,1、2、4周血白细胞和血小板均较栓塞前明显升高,差异有统计学意义（P〈0.05和P〈0.01）。结论 部分脾栓塞治疗脾功能亢进,能提高血细胞数量,而使患者的肝动脉化疗能正常进行,延长患者生存期。     

Extrahepatic portal hypertension in children: observations on three surgical procedures

This paper presents a comparative prospective study of three modalities of surgical treatment for extrahepatic portal hypertension in children: central splenorenal shunt after splenectomy (CSS), side-to-side lienorenal shunt (SSLR) without splenectomy, and splenectomy and gastroesophageal devascularization (SGD). In an 18-month period, 27 procedures were performed: 10 CSS, 10 SSLR, and seven SGD. The outcomes were evaluated by fall in portal pressures, hematological parameters, shunt patency, splenic regression, and disappearance of esophageal varices. All three procedures were comparable in the fall of portal pressure after surgery. The average blood loss and operating time were statistically significant in favor of SSLR compared with CSS. At 3-month follow-up, shunt patency was confirmed by duplex Doppler study in all the patients in the SSLR group and in nine out of 10 patients in the CSS group. In the CSS and SGD groups, hypersplenism resolved in all the patients. In the SSLR group, blood counts improved in only five out of eight affected children. No patient re-bled during a follow-up of 3–5 years. There were no cases of hepatic encephalopathy or overwhelming postsplenectomy sepsis. In conclusion, CSS is useful when there is a large spleen, severe hypersplenism, and a shuntable splenic vein. SSLR is suitable when there is only mild splenomegaly, mild hypersplenism, and a shuntable splenic vein. Splenectomy and devascularization is the choice when there is no shuntable splenic vein.     

Indications and complications of splenectomy for children with sickle cell disease

Background

Sickle cell anemia (SCA), which is characterized by high hemoglobin (Hb) F level and persistent splenomegaly into the older age group (up to 18 years of age) or even adults, is one of the commonest hemoglobinopathies in the Eastern Province of Saudi Arabia. This makes them liable to develop splenic complications requiring splenectomy. This is a review of our experience in the management of 134 children with SCA who had splenectomy as part of their management at our hospital, with emphasis given to the indications and complications of splenectomy.

Patients and methods

The medical records of all children who had splenectomy at our hospital were retrospectively reviewed for the following: age at splenectomy, sex, Hb electrophoresis, indication for splenectomy, preoperative investigations, type of surgery, spleen weight, histology, perioperative management, and postoperative complications.

Results

From 1990 to 2004, 170 children with various hematologic disorders had splenectomy at our hospital. Of these, 134 had SCA (118 had sickle cell disease and 16 had sickle-β-thalassemia). Recurrent acute splenic sequestration crisis (ASSC) was the commonest indication for splenectomy in 103 (76.9%) patients, followed by hypersplenism in 18 (13.4%). Seven (5.2%) of our patients had splenectomy for splenic abscess (SA) and 2 had splenectomy for massive splenic infarction; 103 (61 boys, 42 girls) patients with a mean age of 7.6 years (range, 1.8-13 years) had splenectomy for ASSC. Their mean Hb F level was 20.5% (range, 9.2%-39.6%). Thirty-two of them had major attacks. Their Hb levels at the time of admission ranged from 1.4 to 4.1 g/dL (mean, 2.5 g/dL). The remaining 71 had minor recurrent attacks. Eighteen had splenectomy for hypersplenism and all had a significant increase in their blood parameters after splenectomy. Seven had splenectomy for SA. In 5 patients, Salmonella was the causative organism; in 1, it was Enterobacter sakazaki, whereas in 1, no organisms were identified. Two of our patients had splenectomy for massive splenic infarction because of persistent left upper quadrant abdominal pain, and 1 had splenectomy for splenomegaly with a nonfunctioning spleen. Twenty-eight (21%) of our patients had splenectomy and cholecystectomy. In 4 patients, this was because of symptomatic gallstones, whereas in the other 24, it was because of asymptomatic gallstones discovered on ultrasound. There was no mortality, but 8 (6%) developed postoperative complications.

Conclusions

With good perioperative management, splenectomy in children with SCA is not only safe, but also beneficial in treating SA, reducing the patients' transfusion requirements, eliminating the risks of ASSC, and eliminating the discomfort and mechanical pressure of the enlarged spleen. Abdominal ultrasound should be done routinely preoperatively for all children with SCA undergoing splenectomy, and if gallstones are discovered, they should undergo concomitant cholecystectomy. This is even so for asymptomatic gallstones. The addition of cholecystectomy to splenectomy does not increase the morbidity, but eliminates the subsequent complications of gallstones and simplifies their future management in case of abdominal crisis as the possibility of cholecystitis is eliminated.     

丝线加明胶海绵脾脏栓塞治疗脾功能亢进

目的　探讨部分脾栓塞（ＰＳＥ） 治疗脾功能亢进（ 脾亢） 的临床应用价值,寻找理想的栓塞剂及合理使用方法,以提高脾栓塞疗效。方法　将４０ 例肝硬化脾亢患者随机分为两组：治疗组３０ 例,用真丝线段加明胶海绵双重栓塞;对照组１０ 例,单用明胶海绵栓塞。栓塞面积控制在５０％ ～７０ ％ 。结果　治疗组３０ 例,获ＣＲ１９ 例（６３ ％） ,ＰＲ７ 例（２３％ ） ,总有效率８６％ 。１ 年复发率３２％ 。对照组１０例,获ＣＲ６ 例（６０ ％ ）,ＰＲ２ 例（２０ ％ ）,总有效率８０％ 。１ 年复发率６６％ 。结论　脾亢患者丝线加明胶海绵双重栓塞,其疗效优于单用明胶海绵。两者近期效果无显著性差异（ Ｐ＞ ０．０５）,但１ 年复发率前者明显低于后者（ Ｐ＜０ ．０５）。     

射频消融治疗犬继发性脾脏肿大的影像学和病理学关系

目的：通过观察射频消融(RFA)脾脏治疗继发性脾肿大犬模型的影像学和病理学改变，探讨RFA治疗脾功能亢进的可行性。方法：16只健康杂种犬随机分为组Ⅰ(脾静脉结扎，4只)和组Ⅱ(脾静脉结扎 RFA，12只)，结扎脾静脉诱导瘀血性脾肿大，3周末组Ⅱ动物剖腹行RFA毁损脾脏。RFA后观察动物并发症，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扫描显示，脾静脉结扎后脾脏明显肿大并可持续2个月以上，脾脏RFA后病灶呈节段性毁损，包括高密度的坏死区和外周低密度的梗死区——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。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，梗死区逐渐吸收、纤维化后最终消失，有活性脾脏组织内血管闭塞、脾窦消失、纤维蛋白沉积——“脾脏实性变”是脾脏缩小的病理基础。结论：RFA治疗实验性脾肿大和脾功能亢进是可行和安全的，RFA后脾脏独特的影像学和病理学变化可作为将来I临床实施RFA治疗脾功能亢进的疗效和随访观察的指标。