脾动脉阻断联合射频消融术治疗脾功能亢进的疗效观察

目的：总结脾动脉球囊阻断联合脾脏射频消融术（RFA）治疗肝硬化门静脉高压型脾功能亢进的有效性及经验。方法在脾动脉球囊阻断状态下对15例脾功能亢进患者行经皮穿刺脾脏RFA, RFA平均时间为（46．4±5．4）min。术后3 d、1周、1个月、3个月和6个月监测血常规,术后1个月复查腹部CTA。结果1例患者术后出现左侧大量血性胸腔积液,给予止血及胸腔积液引流后好转,其余患者未发生严重并发症。 RFA后1个月行腹部CTA检查示RFA毁损范围占脾脏总体积的比率为34．3％～71.8％,平均（56.20±13.09）％。术前血细胞计数示：白细胞为（3.88±1.75）×109/L,红细胞（4.06±0.37）×1012/L,血小板（48.14±11.33）×109/L。 RFA术后1个月复查示：白细胞（5.62±1.61）×109/L,血小板（132.29±33.20）×109/L;与术前相比,血小板和白细胞显著升高（P<0．05）。结论脾动脉球囊阻断联合RFA治疗肝硬化门静脉高压型脾功能亢进具有较高的安全性,且近期疗效可靠。     

手术治疗肝豆状核变性并脾功能亢进的疗效评价

目的：评价脾切除术联合胃底贲门周围血管离断术治疗肝豆状核变性并脾功能亢进的疗效。方法148例肝豆状核变性并脾功能亢进患者行脾切除术联合胃底贲门周围血管离断术治疗,检测患者的血常规、肝功能变化,评定手术疗效。结果手术后1周,患者血小板（PLT）、白细胞（WBC）较手术前显著升高（P ＜0．05）,甚至超过正常范围;手术后1月的 PLT、WBC水平则显著回落,恢复正常水平。谷丙转氨酶、谷草转氨酶、总胆红素术前处于较高水平,术后1周较术前进一步升高（P ＜0．05）,而术后1月时其水平较术前及术后1周均有显著下降（P ＜0．05）。结论脾切除术联合胃底贲门周围血管离断术治疗肝豆状核变性并脾亢,对恢复外周血细胞数量、保护肝功能均有显著作用。     

部分脾栓塞术临床应用进展

部分脾栓塞术(PSE)作为一种非手术方法可规避脾切除术带来的风险。除治疗脾功能亢进、血小板减少症、脾外伤、脾动脉瘤外,还能缓解肝移植术后脾动脉盗血综合征从而改善受肝血供;减少门脉高压所致食管胃静脉曲张破裂出血的风险;改善外周血象以耐受大量化疗药物或干扰素治疗;治疗特发性血小板减少性紫癜等血液系统疾病。现就PSE临床应用进展作一综述。     

Coagulation profile and platelet function in patients with extrahepatic portal vein obstruction and non-cirrhotic portal fibrosis

BACKGROUND AND AIMS: Coagulation disorders commonly develop in patients with cirrhosis of the liver. They have also been reported in patients with non-cirrhotic portal fibrosis (NCPF) and extra-hepatic portal venous obstruction (EHPVO); the two conditions with portal hypertension and near-normal liver functions. The spectrum and prevalence of coagulation abnormalities and their association with the pathogenesis of these diseases and with hypersplenism was prospectively studied. METHODS: Eighteen EHPVO patients that included an equal number of NCPF patients and 20 healthy controls were prospectively studied. The coagulation parameters assessed included: international normalized ratio, partial thromboplastin time, and fibrinogen and fibrinogen degradation products. Platelet aggregation and malondialdehyde levels were measured. RESULTS: Both EHPVO (83%) and NCPF (78%) patients had a significantly prolonged international normalized ratio and a decrease in fibrinogen and platelet aggregation. The EHPVO patients had a significant prolongation in partial thromboplastin time (67% patients), with increased levels of fibrinogen degradation product levels occurring in all patients; these were normal in NCPF patients. Platelet malondialdehyde levels were normal in both groups. Hypersplenism was present in four EHPVO and seven NCPF patients. It did not significantly influence the coagulation profile in either NCPF or EHPVO patients. CONCLUSIONS: Coagulation anomalies are common and significant in both NCPF and EHPVO patients, suggestive of a mild disseminated intravascular coagulation disorder. These imbalances could be caused by chronic subclinical endotoxemia and cytokine activation after the initial portal thromboembolic event. The persistence of these abnormalities in adolescent patients indicates an ongoing coagulation derangement.     

Laparoscopic splenectomy may be a superior supportive intervention for cirrhotic patients with hypersplenism

Background and Aims: To evaluate and compare laparoscopic splenectomy and partial splenic embolization as supportive intervention for cirrhotic patients with hypersplenism to overcome peripheral cytopenia before the initiation of and during interferon therapy or anticancer therapy for hepatocellular carcinoma. Methods: Between December 2000 and April 2008, 43 Japanese cirrhotic patients with hypersplenism underwent either laparoscopic splenectomy or partial splenic embolization as a supportive intervention to facilitate the initiation and completion of either interferon therapy or anticancer therapy for hepatocellular carcinoma. We reviewed the peri‐ and post‐intervention outcomes and details of the subsequent planned main therapies. For interferon therapy, the rate of completion, the rate of treatment cessation and virological responses were evaluated. Anti‐cancer therapies for hepatocellular carcinoma included liver resection, ablation therapy, intra‐arterial chemotherapy, and transarterial chemoembolization. Results: All patients tolerated the operations well with no significant complications. The platelet count was significantly higher in the laparoscopic splenectomy group than in the partial splenic embolization group at 1 and 2 weeks after the intervention. Interferon therapy was stopped in two patients in the partial splenic embolization group due to recurrent thrombocytopenia whereas all patients in the laparoscopic splenectomy group completed interferon therapy. The planned anticancer therapies were performed in all patients, and were completed in all patients without any problems or major complications. Conclusion: Laparoscopic splenectomy may be superior to partial splenic embolization as a supportive intervention for cirrhotic patients with hypersplenism. Future prospective, randomized controlled patient studies are required to confirm these findings.     

Role of the spleen in liver fibrosis in rats may be mediated by transforming growth factor beta-1

BACKGROUND: The effect of the spleen on the cirrhotic liver is unknown. Transforming growth factor-beta 1 (TGF-beta 1), which plays a crucial role in the matrix production during liver fibrosis, is an inhibitory factor regarding the regeneration of hepatocytes. In this study, we investigated the TGF-beta 1 production in the spleen of cirrhotic rats and the effects of a splenectomy on the healing process from liver fibrosis. METHODS: Thirty-six Wistar male rats were used. Thioacetamide (TAA) was administered intraperitoneally for 24 weeks. The rats underwent either a sham operation (TAA + Sham) or a splenectomy (TAA + SPL). The improvements in liver fibrosis and liver regeneration were investigated 10, 30 and 60 days after the operations in each group. The effect of a splenectomy on the plasma concentration of TGF-beta 1 in the portal vein was investigated by ELISA. The TGF-beta 1 expressions in the spleen were measured using immunohistochemical staining and the degree of such expression was measured using RT-PCR. The activity of TGF-beta 1 in the portal vein of TAA + Sham and TAA + SPL was assessed by the inhibiting effect of rat parenchymal hepatocyte proliferation in primary culture. RESULTS: Liver regeneration (PCNA-labeling index) in the TAA + SPL rats was stimulated more at 10 and 30 days after the operation (P < 0.05) than in the TAA + Sham rats, and the improvement of liver fibrosis (fibrosis rate) in the TAA + SPL rats was higher at 60 days (P < 0.05) than in the TAA + Sham rats. The plasma concentration of TGF-beta1 of the portal vein in TAA + SPL rats was significantly lower than in the TAA + Sham rats for each period. Immunohistochemically, TGF-beta1-positive stained cells were recognized in the spleen macrophages in the red pulp of cirrhotic rats. The plasma of the TAA + Sham rats at 10 and 30 days after the operation was significantly stronger than that of the TAA + SPL rats in inhibiting the proliferation of rat hepatocytes of primary culture. Inhibitory effects were then dose-dependently neutralized by monoclonal TGF-beta 1 antibody. CONCLUSION: Spleen-derived TGF-beta 1 may thus play an inhibitory role in the healing of liver cirrhosis by inhibiting the regeneration of the damaged liver.     

部分脾动脉栓塞术治疗肝硬化性脾功能亢进的临床评价

目的探讨部分脾动脉栓塞术（PSE）对治疗肝硬化性脾功能亢进的疗效及临床价值。方法对20例肝硬化性脾功能亢进患者进行了PSE;观察术前术后外周血象的变化、腹水消退及并发症发生情况。结果 20例患者术后外周血象较术前明显改善。8例有腹水者,腹水消失6例,腹水减少2例。术后并发症主要有左上腹疼痛（15例）、发热（10例）、左侧胸水（3例）。结论 PSE对治疗肝硬化性脾功能亢进症有明显疗效和重要的临床价值。选择合适的病人和严格的操作技术能避免严重并发症的发生。     

探讨部分性脾动脉栓塞术治疗肝硬化脾功能亢进的临床应用

目的通过临床对肝硬化脾功能亢进患者应用部分性脾动脉栓塞术,分析患者的临床疗效以及该方法的应用价值。方法选取肝硬化合并脾功能亢进患者30例,采用Seldinger技术在患者的股动脉进行穿刺,插管至脾中、下极动脉,将明胶海绵颗粒注入其中,形成患者脾动脉远端部分性栓塞,范围大约为40%～50%。结果肝硬化脾功能亢进患者经过部分性脾动脉栓塞术后,外周血白细胞、血小板以及红细胞出现不同程度的升高表现,与治疗前比较差异有统计学意义(P<0.05)。结论部分性脾动脉栓塞术具有明显的疗效,对患者的创伤小,掌握栓塞要求能够避免并发症的发生。     

部分脾动脉栓塞后机体体液免疫的变化

目的：观察部分脾动脉栓塞治疗继发性脾功能亢进后机体体液免疫的变化。材料与方法： 32例肝炎、肝硬化、继发性脾功能亢进者,在 DSA引导下,把 5F RS型或 Yashiro导管选择性地插入脾动脉内, 1mm× 1mm× 1mm明胶海绵块 120～ 180枚与抗菌素和造影剂混合后,在透视监视下分次注入脾动脉。栓前、栓后 1、 3、 7、 14、 28和 56天分别抽血 3ml,测定血清中 IgG、 IgA、 IgE、白介素－ 2和肿瘤坏死因子的含量。结果：栓塞后动脉期,脾动脉 5级以下分支未显影,实质期 70％～ 90％脾实质未显影。栓后不同时期,血清中 IgG、 IgA、 IgE、白介素－ 2和肿瘤坏死因子含量无显著性变化。结论：部分脾动脉栓塞治疗脾功能亢进,保留了部分脾脏组织,对机体体液免疫功能无显著影响。