成人门静脉海绵样变性的诊断和治疗

目的 探讨成人门静脉海绵状变性（ＰＶＣＴ）的诊断和治疗。方法 对１５例成人ＰＶＣＴ的临床资料进行回顾性分析。结果 所有病人术前均经Ｂ超或多普勒超声检查提示肝脏正常及ＰＶＣＴ,并经经皮脾穿刺门静脉造影或选择性肠系膜上动脉造确诊。９例行脾动脉结扎、冠状静脉结扎、肠系膜上民下腔静脉Ｃ型架桥术（肠腔Ｃ型架桥）;１例行脾动脉结扎、脾肾静脉Ｃ型架桥术;５例已行脾切除加断流术后再出血者４例行肠腔Ｃ型架桥术,１例     

成人门静脉海绵样变性的诊断分型及处理对策

目的 建立成人门静脉海绵样变性的分型,并根据分犁制定相应的外科处理对策.方法 对63例成人门静脉海绵样变性患者的临床资料进行回顾性分析,总结不同类型的门静脉海绵样变性的诊断和处理方法,提出不同类型的门静脉海绵样变性的分型及外科处理对策.结果 根据影像学检查和手术探查结果,将成人门静脉海绵样变性分为4型:Ⅰ型,门静脉主干海绵样变波及门静脉肝内分支,主要处理方法是门-体分流术(肠-腔和脾-腔等)或附加门-奇断流术;Ⅱ型,门静脉主干海绵体样改变,同时病变累及部分肠系膜上静脉或部分脾静脉,主要处理方法是门-体分流术(肠-腔和脾-腔等)或附加门-奇断流术;Ⅲ型,门静脉海绵样变波及整个门静脉系统,主要处理方法是门肺分流术(脾肺固定术等)、肠系膜下静脉-下腔静脉分流术或附加门-奇断流术;Ⅳ型,以上的任何类型合并了胆道和(或)胰腺的病变,主要处理方法是选择处理主要病变且对两类病变分期处理. 结论多普勒超声和多排CT三维血管重建技术是诊断本病的理想方法;正确的术前诊断、分型并结合个体化的处理对策在成人门静脉海绵样变性治疗中具有重要的意义.     

联合手术治疗儿童门静脉海绵样变性肝前性门静脉高压症

目的评估联合手术治疗儿童门静脉海绵样变性引起的肝前性门静脉高压症的疗效。方法2例门静脉海绵样变性和反复上消化道出血的患儿行脾切除脾肾静脉分流加贲门周围血管离断术;1例因断流术后再出血,行肠系膜上-腔静脉分流加贲门周围血管离断术,分析这3例的临床疗效。结果手术并发症和手术死亡率为0,随访13~31个月,肝功能正常,贫血纠正。无再出血、门静脉高压性胃病和肝性脑病。结论联合手术,特别是脾切除脾肾静脉分流加贲门周围血管离断术,安全、有效,适用于各种血流动力学状态,应成为治疗儿童门静脉海绵样变性引起的肝前性门静脉高压症的首选术式。     

系-腔分流术治疗门静脉高压症术后再出血的临床研究

目的探讨系-腔C形、H形架桥术对门脉高压症再出血的临床疗效及肠系膜上静脉外科干解剖变异时的临床处理.方法总结2002年1月至2004年8月36例门脉高压症术后再出血病例资料,其中脾切除、断流术后再出血21例,近端脾肾分流术后再出血9例,远端脾肾分流术后再出血4例,近端脾肾分流术＋断流术后2例;再出血后行系-腔C形架桥术18例,系-腔H形架桥术12例,肠系膜上静脉外科干解剖变异改行肠系膜下静脉-下腔静脉分流术4例,改行冠腔分流术2例.通过术中测压、术后B超测定吻合口血流量以及胃镜、肝功能随访评价系-腔分流术临床疗效.结果术后门脉降压明显,随访6个月至3年,吻合口通畅,胃底静脉曲张减轻,无一例再出血,无严重并发症,无一例死亡.结论系-腔分流术能有效的治疗门脉高压症术后再出血,其中C形架桥术降压效果最明显;当肠系膜上静脉外科干解剖变异时,应及时选择其它分流方法.     

成人肝外型门静脉高压症诊治分析

目的: 探讨成人肝外型门静脉高压症(EHPH)的临床特点和治疗策略. 方法: 回顾分析对6例EHPH病人的诊治过程. 结果: 5例病人以反复上消化道出血及脾亢为主要临床表现,经彩色多普勒超声及门静脉造影检查,3例有典型门静脉海绵样变(CTPV)表现,1例为门静脉血栓形成,1例为卵巢癌转移压闭脾静脉.断流术3例,肠腔分流术1例,内镜下曲张静脉硬化及结扎治疗2例,平均随访8.4个月,死亡2例. 结论: 成人EHPH病因复杂,诊断主要依靠彩超及门静脉造影,治疗方案根据病人具体情况而定.     

间接门静脉造影对诊治肝前型门静脉高压症的意义

目的：探讨间接门静脉造影对诊断肝前型门静脉高压症以及对手术治疗的指导意义。方法：回顾分析近3年来收治的肝前型门脉高压症11例患者的临床资料，依照间接门静脉造影和/或彩超结果，全部确定为肝前型门脉高压症。施肠系膜上静脉-下腔静脉转流术5例，门静脉-下腔静脉转流术1例，脾切除、脾静脉-肾静脉转流术2例，肠系膜上静脉门静脉探查术、门奇静脉断流术1例，未行手术2例。结果：经转流手术治疗的患者术后脾亢消失，未再发生上消化道出血。结论：间接门静脉造影检查是诊断肝前型门脉高压症的金标准，对选择手术治疗方法有指导意义。     

肠腔分流并选择性冠状血管缝扎术治疗成人门静脉海绵样变性引起的上消化道出血

目的 探讨肠腔分流并选择性冠状血管缝扎术对成人门静脉海绵样变性的治疗作用及其临床价值.方法 对26例成人门静脉海绵样变性行肠腔分流、脾动脉结扎、选择性冠状静脉缝扎术治疗患者的临床资料进行回顾性分析. 结果 本组无手术死亡病例,分流术后自由门静脉压力为(24.8±2.7) cm H2O,与术前的(34.4±4.7)cm H2O比较差异有统计学意义(t=12.30,P＜0.01).术后并发轻微肝性脑病l例,应激性溃疡出血1例,均通过非手术治疗后痊愈.23例得到随访,随访时间6个月～4.5年,无再出血病例.结论 肠腔分流并选择性胃冠状血管缝扎术对成人门静脉海绵样变性是安全、有效、合理的手术方式.     

肝前型门静脉高压症的诊治

目的探讨肝前型门静脉高压症的临床特点、诊断、治疗方法的选择及疗效。方法回顾性分析第二炮兵总医院及北京协和医院2000年1月至2009年5月期间收治的46例肝前型门静脉高压症（包括2例Abern-ethy畸形）患者的临床资料。全部患者均根据间接门静脉造影、CT血管造影和（或）彩超检查结果确诊为肝前型门静脉高压症。行肠系膜上静脉-下腔静脉分流术23例;脾切除、脾静脉-肾静脉分流术8例;门静脉-下腔静脉分流术1例;附脐静脉-颈内静脉分流术2例;门奇静脉断流术3例;脾切除、门奇静脉断流术1例;乙状结肠暂时性造瘘,6个月后闭瘘1例;大部分小肠切除术1例;经股动脉插管溶栓4例;未行手术2例,仅给予护肝及对症治疗。结果44例患者随访2个月～5年,平均23.4个月,1例未手术者失访。34例行分流手术治疗的患者术后脾功能亢进症状消失,未再发生上消化道出血;行断流术者术后13个月及2年因再次出血行肠系膜上静脉-下腔静脉分流术2例;断流术后8个月因再次出血死亡1例;溶栓治疗后40d因肠坏死死亡1例,1例未手术的患儿出院4个月后再次出现黑便经保守治疗好转。结论肝前型门静脉高压症的治疗以降低门静脉压力为主,各种分流手术及肠系膜上动脉和（或）脾动脉置管溶栓安全有效,但需根据个体情况施行。     

三联手术治疗门静脉高压症食管静脉曲张破裂出血

目的　评价三联手术(人造血管肠腔静脉C型架桥、冠状静脉结扎、脾动脉结扎)治疗门静脉高压症(PHT)上消化道出血的效果。方法　对采用三联手术治疗的58例门静脉高压症上消化道出血患者的临床资料进行回顾性分析。结果　手术前胃网膜静脉压为27～45cmH2O,术后为25～43cmH2O,平均下降8cmH2O。术后因脑血管意外死亡1例。2例有轻度肝性脑病,经对症治疗后好转;3例发生乳糜瘘,分别在手术后5,10d和3个月后自行消失。随访1个月～6年的共41例,无再出血病例,无肝性脑病发生。所有病人脾机能亢进消失。腹水消失20例,明显减少10例,无1例增加。肝功能好转10例,下降3例,28例变化不明显。B超或彩色多普勒检查,40例人造血管均通畅。结论　本手术主要适应于以下原因引起的门静脉高压:①单纯化肝静脉闭塞(布加综合征的一种病理类型);②门静脉主干血栓形成成海绵样变性引起的肝前性门静脉高压;③肝内型门静脉高压行断流术后再发出血或未行手术,肝功能为ChildA和B级者。     

断流联合自体脾静脉游离移植的肠腔分流术治疗门脉高压症

目的探讨断流加自体脾静脉游离移植肠——腔静脉“H”架桥分流术治疗门静脉高压症的价值。方法回顾性分析2002年10月～2003年12月间完成的9例病例资料及随访资料。结果断流联合自体脾静脉游离移植肠～腔静脉架桥分流8例．门～腔静脉架桥分流1例。无手术死亡病例,术后食道静曲张消失5例,明显好转4例．随访3～14月,分流道均通畅。结论该联合术式近期效果理想,具有创伤小．不需要抗凝,费用低廉等优点．值得进一步研究。     

成人门静脉海绵样变63例的诊断与外科治疗

目的 总结成人门静脉海绵样变(cavernous transformation of portal vein,CTPV)的诊断与外科治疗经验.方法 回顾性分析1976年至2006年成人CTPV 63例临床资料.结果 成人CTPV的诊断依据:(1)脾脏肿大、脾功能亢进症状,半数以上病例并发上消化道出血、中等或小量腹水,肝脏无肿大、肝功能基本正常.(2)彩色Dopple超声检查显示门静脉内径变细、闭塞或栓塞,肝门部向肝血流紊乱并呈"蜂窝状",管道内为红蓝相间的血流信号.(3)CT及MRI显示门静脉阻塞或狭窄及发现侧支循环形成,边缘呈波浪状.(4)肠系膜上动脉及腹腔动脉造影静脉期门静脉主干未显影,肝门区广泛迂曲,呈团块状血管影.成人CTPV的治疗:63例均行手术治疗其中脾切除、门奇静脉断流术23例;脾切除、远端脾肾静脉分流术32例;门奇静脉断流术联合分流术8例.CTPV合并胆道疾病宜先处理门静脉高压症.该组无手术病死病例,术后近期血常规及血小板计数均恢复正常.结论 CTPV一旦确定诊断并有手术适应证,就应积极手术治疗;选择合适的术式是手术成功的关键.

Abstract：

Objective To summarize the diagnosis and surgical treatment of the cavernous transformation of portal vein (CTPV). Methods Clinical data of 63 patients with adult CTPV trea-ted in our hospital from 1976 to 2006 were retrospectively analyzed. Results The diagnosis of CT-PV was comfirmed according to (1) The main symptoms were repeated haematemesis, hemafecia, hy-persplenotrophy, hypersplenia and normal hepatic function. (2) B uhrasonography or ultrasonic Doppler manifested that portal vein thinning or obstruction or embolism, honeycomb appearance con-duit can be seen around. Portal vein frequency spectrum can be seen in the honeycomb appearance con-duit. (3) CT and MR scan materials were exhibited that the main portal vein and its branches lost the normal shape and had the shaggy edge. (4) percutaneous splenoportography or selective arteriography of superior mesenteric artery showed that occlusion of the main branch of portal vein at the porta hepa-tis was revealed, and a masslike network of tortuose veins around the porta hepatis and many small ir-regular veins radiating from the network to the liver were demonst rated. Splenectomy and devaseu-larization was performed in 23, spleneetomy and splenorenal shunt in 32, portal systemic shunt plus porta-azygous devascularization in 8. Portal hypertension was treated first in CTPV with disease of biliary tract. No death happened. The rascult of haemogram recovered in a short period of time.Conclusion Once the patients are diagnosed to suffer from adult CTPV, they should receive explora-tory laparotomy. It is important to choose the most effective treating method for the disease.     

门静脉高压断流术后上消化道再出血的治疗策略：附56例报告

目的：探讨门静脉高压断流术后上消化道再出血的原因及分流术的治疗作用。方法：回顾性分析10年间收治的门静脉高压断流术后上消化道再出血56例患者的临床资料。其中54例再次行分流手术，其中急诊手术5例，择期手术49例，包括肠系膜上静脉－下腔静脉人工血管反C型分流术(肠腔分流术)45例，门静脉－下腔静脉分流术5例，肠系膜下静脉－下腔静脉人工血管分流术4例。结果：54例手术治疗者术后出现乳糜漏13例，均治愈;肝性脑病5例，治疗好转4例，死亡1例;术后3d，死于肝衰竭1例。另非手术治疗2例中1例死于肝衰竭;1例死于失血性休克。随访52例，随访时间6个月至9年;随访期间无上消化道再出血病例;死亡7例，其中2死于原发性肝癌，3例死于肝衰竭、肝性脑病，2例死于非相关性疾病。结论：对于门静脉高压断流术后上消化道再出血患者首先采取积极的非手术治疗，然后行择期手术;积极非手术治疗48h无效者，应急诊手术治疗。手术方式首选肠系膜上静脉－下腔静脉人工血管反C型分流术(肠腔分流术)，尤其对伴有门静脉血栓、门脉高压性胃病患者。     

Management of recurrent hemorrhage in portal hypertension

123 cases of recurrent hemorrhage were studied. It was found that the rebleeding rate differed with different original operations. Those with unsatisfactory portal decompression or persistence of varices were prone to rebleeding. Rebleeding within one year occurred in 47.96%, and in late stage in 52.04%. Early postoperative rebleeding should be treated conservatively with intensive circulatory resuscitation. Repeated rebleeding occurred in 89% of the patients, reoperation should be carried out with definite indications. Emergency surgery was usually not recommended. On the operation, portal vein thrombosis was found in 58.8% of the patients, and dilatation of the superior mesenteric vein in 82.9%. Of the fifty six rebleeding cases treated surgically, 21.4% died of further bleeding in 5 years compared with 50.7% treated conservatively. Rebleeding occurred in 62.5% of disconnection cases and in 31.2% of shunt cases. The authors performed mesocaval side-to-side anastomosis in those with enlarged superior mesenteric vein, and restricted portocaval shunt in those without portal thrombosis. Rebleeding patients with regional portal hypertension were better treated with devascularization.     

脾腔分流联合断流术后门静脉系统血栓形成的临床分析

目的 探讨脾腔分流联合断流术治疗门静脉高压症术后门静脉系统血栓形成的临床特征,为防治提供线索.方法 回顾性分析接受脾腔静脉分流联合断流术治疗的110例门静脉高压症病人及接受断流术的92例病人术后门静脉血栓形成、诊治以及继发消化道再出血情况,并比较两种术式对门静脉系统血栓形成的影响.结果 联合手术组术后门静脉系统血栓发生率10.O%,再出血率3.6%,低于断流组的22.8%(P<0.05)和10.8%(P<0.05).结论 脾腔静脉分流联合断流术是减少门静脉系统血栓形成的理想术式,术后早期抗凝治疗对预防血栓形成具有重要意义.     

门脉侧支循环状态与肝硬化门脉高压的术式选择

目的通过16层螺旋CT门静脉成像（CTPV）,了解肝硬化门脉高压患者门脉侧支循环状态,探讨其在选择合理手术方式中的价值。方法73例肝硬化门脉高压患者,分别进行脾切除术（14例）、贲门周围血管离断术（37例）、分流术（17例）和断分流联合术（5例）,所有患者术前均行CTPV检查,获得门脉侧支循环血管的清晰图像。结果CTPV重建门脉侧支循环系统。73例患者中,以胃左、食管旁、脾静脉曲张为主要表现55例（75．3％）,伴有脐静脉曲张伴腹壁静脉曲张5例（6．8％）,伴有胃短／胃后静脉曲张9例（12．3％）,伴有门静脉海绵样变或栓塞9例（12．3％）,肠系膜上静脉血管闭塞3例（4．1％）。结论CTPV重建可较好地显影门静脉侧支循环状态,结合肝功能分级和门脉血流动力学等资料,有助于术者选择合理手术方式,实现门脉高压症的个体化治疗。     

Portosystemic shunt for the treatment of portal vein thrombosis following orthotopic liver transplantation

Abstract The efficacy of the portosystemic shunt operation for the treatment of portal vein thrombosis following orthotopic liver transplantation was demonstrated. From 1 July 1988 to 31 December 1991 42 portosystemic shunt operations were performed at our centre. In six of these cases portal vein thrombosis after orthotopic liver transplantation (OLT) was the indication for the procedure. All the patients retained adequate liver function but they demonstrated manifestations of significant portal hypertension, mainly variceal rebleeding. Two of the patients were children. Three patients underwent distal splenorenal shunt (DSRS), one mesocaval and one side-to-ide splenorenal shunt and the last one side-to-ide splenorenal shunt which was converted to DSRS 2 weeks later. All these patients were doing well after 30 months mean follow-up time without rebleeding or other signs of portal hypertension and none had so far required retransplantation.     

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。     

Splenic-intrahepatic left portal shunt in an adult patient with extrahepatic portal vein obstruction without recurrence after pancreaticoduodenectomy

In the last decade, a superior mesenteric-intrahepatic left portal shunt (Rex shunt) has been reported for successful management of extrahepatic portal vein obstruction in children. However, in adults, a mesocaval shunt has been generally performed for the surgical management of extrahepatic portal vein obstruction because of the complexity of the underlying disease and the difficulty of the superior mesenteric-intrahepatic left portal shunt. We herein report an adult patient who was successfully treated by splenic-intrahepatic left portal shunt with an artificial graft (6-mm polytetrafluoroethylene) for complete obstruction of the extrahepatic portal vein following pancreaticoduodenectomy. The shunt procedure not only relieved portal hypertension but also restored hepatic portal flow. In the near future, the Rex shunt should be considered for a beneficial management of extrahepatic portal vein obstruction, even in adults.     

经颈静脉肝内门体分流术治疗门静脉海绵样变并发门静脉高压

目的探讨经颈静脉肝内门腔静脉分流术治疗合并门静脉海绵样变的门静脉高压症的疗效。方法 8例反复上消化道出血患者(均有肝硬化、门静脉高压)术前均经B超及CT等影像学证实伴有门静脉海绵样变,门静脉主干及左右支有完全或部分闭塞,对其行TIPS治疗,并评价疗效。结果对7例患者均成功施行TIPS术,1例失败,6例为先经皮穿刺右肝门静脉分支,建立经门静脉右支至主干通道,并行球囊扩张成形治疗。其中4例经常规TIPS途径由肝右静脉穿刺门静脉右支建立门腔静脉分流道,2例由门静脉右支穿刺右肝静脉建立门腔静脉分流道。1例穿刺门静脉右支失败,改由常规TIPS途径穿刺门静脉左支建立门腔静脉分流道。门静脉压力由术前的(33.72±8.35)mmHg降低至术后的(21.43±7.64)mmHg;1例在术后6个月发现分流道狭窄,再次植入支架后恢复通畅。1例术后5个月再发黑便,复查提示分流道堵塞,并门静脉广泛血栓形成,放弃进一步治疗。另5例在12个月随访中分流道通畅,未再发消化道出血。结论 TIPS是治疗伴门静脉海绵样变的门静脉高压症的安全、有效的方法。