腹腔镜肝切除术中肝门大血管意外损伤的处理

目的探讨腹腔镜肝切除手术中肝门大血管意外损伤腹腔镜下修复的可行性。方法回顾性分析2005年11月至2009年12月144例腹腔镜肝切除术的临床资料,发生肝门大血管意外3例,其中门静脉主干损伤1例,门静脉右支损伤1例,肝左静脉损伤1例,均行腹腔镜手术修复损伤。结果 3例血管损伤都在腹腔镜下修复,手术时间240～330min,平均290min,术中出血量800～1200ml,平均1000ml,输血400～800ml,平均666.6ml,无死亡及再次手术病例,随访13～15个月,平均13.3个月,未见门静脉血栓形成。结论腹腔镜手术中肝门大血管意外损伤的腔镜下修复是可行的。     

Reconstruction of portal vein using a hepatic vein patch graft after combined hepatectomy and portal vein resection

BACKGROUND: Surgical resection is the only treatment modality that ensures complete tumor removal in patients with liver tumors involving a major portal vein branch or its bifurcation. Restoration of good portal blood flow is essential for recovery in the early postoperative period and for long-term survival. However, such extended resections often result in large defects at the bifurcation of the portal vein that are not amenable to suturing or end-to-end anastomosis. METHODS: A patch graft technique is very useful for reconstruction of long and elongated defects when other methods are not technically appropriate. We describe a simple technique for reconstructing the portal vein using a patch graft obtained from the hepatic vein stump of the resected specimen. CONCLUSIONS: This technique permits surgeons to reconstruct the portal vein without any need for harvesting another vein and with no need for an additional incision.     

Portal vein thrombosis: an unusual complication of laparoscopic cholecystectomy.

BACKGROUND: Complications following laparoscopic cholecystectomy are encountered infrequently due to increasing proficiency in laparoscopic surgery. The occurrence of portal venous thrombosis following laparoscopic cholecystectomy has not been previously described and forms the basis of this report. METHODS: A healthy, 32-year-old, female on oral contraceptives underwent an uneventful laparoscopic cholecystectomy for symptomatic gallbladder disease. Sequential compression devices and mini-dose unfractionated heparin were used before the procedure. The patient was discharged home on the first postoperative day without complaints. She returned 1 week later with nausea, bloating, and diffuse abdominal pain. RESULTS: Ultrasonography of the abdomen revealed thrombosis of the portal vein not seen in the preoperative ultrasound and the superior mesenteric vein. Computer tomography of the abdomen and pelvis on the same day confirmed this finding and showed a wedge-shaped infarction of the right lobe of the liver. The patient was anticoagulated with intravenous heparin. An extensive coagulation workup revealed elevation of the Immunoglobulin G anticardiolipin antibody. A percutaneous transhepatic portal vein thrombectomy was performed. A postprocedure duplex ultrasound of the abdomen demonstrated recannalization of the portal venous system with no flow voids. Anticoagulation therapy was continued, and the patient was discharged home with resolution of her ileus. She was maintained on a therapeutic dose of warfarin. CONCLUSIONS: This case demonstrates an unusual complication of laparoscopic cholecystectomy. It may have resulted from the use of oral contraceptives, elevation of the Immunoglobulin G anticardiolipin antibody, unrecognized trauma, and was accentuated by the pneumoperitoneum generated for the performance of the laparoscopic cholecystectomy. Our case report provides insight and poses questions regarding necessary perioperative measures for thromboprophylaxis in young females on oral contraceptives undergoing elective laparoscopic abdominal surgery.     

原发性肝癌合并门静脉癌栓的治疗策略

门静脉癌栓（portal vein tumor thrombus,PVTT）是原发性肝癌（hepatocellular carcinoma,HCC）的常见并发症,目前的治疗方法有外科手术切除、经肝动脉介入治疗、经门静脉介入治疗、经肝动脉和门静脉双途径介入治疗、放射治疗、消融治疗、肝移植、分子靶向治疗、综合治疗等,本文对上述各种治疗方法的近况进行了评价,以期进一步提高其治疗效果。     

A case of portal vein thrombosis after laparoscopy-assisted splenectomy and cholecystectomy in a child

We report the case of an 8-year-old boy with a red cell membrane disorder who developed, soon after undergoing laparoscopic cholecystectomy and splenectomy, complete thrombosis of the right branch and a partial occlusion of the left branch of the portal vein. The child was affected by a right hemiparesis because of a hypoxic-ischemic disorder that occurred in the first hours of life and was heterozygous for the methylenetetrahydrofolate reductase gene mutation 677C-T.Intravenous heparin and aspirin were initiated on postoperative day 7. Heparin treatment was switched to the subcutaneous route after the first 24 hours. The symptoms subsided 3 days after the beginning of treatment, whereas complete resolution of portal vein thrombosis was observed 2 months later. A review of the literature is reported, and the possible pathogenetic mechanisms underlying portal vein thrombosis are discussed.     

脾切除术后门静脉系统血栓形成的临床分析

目的探讨脾切除术后门静脉血栓形成（portal vein thrombosis,PvT）和肠系膜静脉血栓形成（mesenteric venous thrombosis,MVT）的成因及诊治策略。方法回顾性分析2000年以来脾切除术后门静脉血栓形成及肠系膜静脉血栓形成12例的临床资料。结果280例脾切除后血栓发生12例（4．3％）,其中发生PVT9例（3．2％）,发生MVT3例（1．1％）。9例经积极的全身抗凝、祛聚、溶栓治疗1～2周后好转出院。血栓形成病人均出现白细胞增多,血小板计数升高,D-二聚体检测和凝血功能异常,与治疗后1周相比,差异均有统计学意义（P〈0．05）。2例行小肠切除肠吻合术。1例死于肝功能衰竭。结论脾切除后动态检测血常规、凝血功能等相关指标是预防静脉血栓形成的有效措施,及早诊断和治疗对病人康复起关键作用。     

Portal and mesenteric vein thrombosis after portal vein embolization in a patient with protein S deficiency

Portal vein embolization can be performed safely, and so far no major complications have been reported. We report an extremely rare complication of portal vein embolization, a case of portal and mesenteric thrombosis in a 65-year-old patient with protein S deficiency. Right portal vein embolization was carried out prior to extended right hepatectomy for advanced gallbladder carcinoma involving the hepatic hilus. Computed tomography 14 days after embolization revealed massive thrombosis of the portal and the superior mesenteric veins. A protein S deficiency was found by means of an extensive workup for hypercoagulable state. Portal vein embolization may have triggered a cascade of events that was expressed as portal and mesenteric vein thrombosis resulting from deficiency of protein S. It may be better to determine the concentrations of such coagulation regulators prior to portal vein embolization.     

肝硬化患者脾切除术后门静脉血栓的防治研究进展

门静脉血栓形成是肝硬化晚期门静脉高压症行脾切除术后的一种较为常见和严重的并发症.其发病原因可能主要与患者的凝血机制和血液流变学改变有关.脾切除术后门静脉血栓形成的临床表现取决于形成的急缓、阻塞部位和程度等因素.其治疗原则以改善微循环、解除血小板聚集、防止血栓进展为主.但在临床工作中,门静脉血栓形成的症状、体征常不典型.如果发生漏诊延误治疗,可能会危及患者的生命.本文就目前肝硬化脾切除术后门静脉血栓形成的机制、相关危险因素及防治进展做一综述.     

扩大肝部分切除术后入肝门静脉动脉化对大鼠血流动力学的影响

目的对大鼠行扩大肝部分切除术后利用右肾动脉行入肝门静脉动脉化加门腔分流术,研究该术式对大鼠门静脉血流动力学的影响。方法 Sprague-Dawley大鼠130只,分为A组(动脉化组)47只,行70%扩大肝部分切除术后,用右肾动脉行门静脉动脉化加门腔分流术;B组(肝切组)43只,行70%扩大肝部分切除及右肾切除,阻断门静脉10min;C组(对照组)40只,仅行右肾切除及门静脉主干游离。分别于术后第2、7、14、28天检测门静脉压力、内径和血流量。结果 A组及B组手术成功率分别为85.1%和93.0%,差异无统计学意义,C组手术成功率100%。术后各时间点A组与B、C组比较,入肝门静脉压力、门静脉内径、血流速度和入肝血流量变化均较后两组更明显(P0.01);A组入肝门静脉压力随时间推移有下降趋势,于术后第14天(12.7±0.7)cmH2O达到稳态,与术后第28天(12.4±0.6)cmH2O比较,差异无统计学意义;而A组门静脉内径、血流速度和入肝血流量在术后各时间点间相比差异无统计学意义。B组术后门静脉血流速度均较C组增快(P0.05),门静脉血流量在术后14～28d较C组增加(P0.05)。结论大鼠扩大肝部分切除术后行入肝门静脉动脉化模型稳定可靠,手术成功率理想,动脉化术后门静脉压力明显升高,门静脉内径出现扩张以适应压力变化,入肝血流量明显增加。门静脉血流动力学指标在术后早期即发生改变并取得稳态。     

Outcome of patients with pre-existing portal vein thrombosis undergoing arterialization of the portal vein during liver transplantation

Arterialization of the portal vein is being propagated as a technical possibility in liver transplant recipients with pre-existing portal vein thrombosis. In our own small series, portal vein arterialization (PVA) was carried out in four patients undergoing orthotopic liver transplantation. In three of these cases, the portal vein was anastomosed to the aorta via an interposed iliac artery, and in one case, directly to the hepatic artery. After PVA, all transplants showed regular initial function. Two patients died postoperatively after 19 and 50 days, of intra-abdominal haemorrhage and liver necrosis with thrombosis of the portal vein, respectively. A further patient had previously developed fibrosis of the liver, which led to the death of the patient 11 months after PVA. In the remaining patient, chronic rejection requiring re-transplantation developed 24 months after PVA had been performed. These unfavourable results prompt the conclusion that PVA cannot be recommended as a standard clinical procedure.     

可溶性P-选择素对肝硬化门静脉高压术后门静脉血栓形成的影响

目的探讨可溶性P-选择素对肝硬化门静脉高压症术后门静脉血栓形成的影响。方法检测乙肝肝硬化患者在门静脉高压症围手术期血小板的数量及反映血小板功能的可溶性P-选择素水平的动态变化,比较其在有门静脉血栓形成组患者及无血栓形成组患者间的差异。结果血栓形成组患者及无血栓形成组患者间,血小板数量无显著差异,而可溶性P-选择素水平在术后第4～6天有显著性差异(P<0.05)。结论乙肝肝硬化患者在行门静脉高压症手术后,血小板功能的变化对门静脉血栓形成可能起着重要的作用。     

肝癌合并门静脉癌栓的治疗

【摘要】〓门脉癌栓是肝癌患者不良预后的重要指标,然而对于合并门脉癌栓的肝癌患者,国际上并没有统一的治疗标准。尽管临床尝试了各种方法,如肝动脉栓塞化疗(TACE),全身药物的系统治疗,局部消融治疗及积极的手术治疗,但治疗效果不尽理想。随着外科技术的发展以及新的技术和药物的研发,希望通过综合的治疗,提高此类患者的治疗效果,延长患者的生存。     

肝移植后门静脉供血障碍的诊断和治疗

目的探讨肝移植术后门静脉供血障碍的诊断和治疗方法。方法2002年4月至2005年8月实施肝移植504例，肝移植术后7d内，每天用彩色多普勒血流显像（CDFI）技术检测门静脉血流1次，无异常发现者改为每周1次，1个月后改为每月1次，半年后改为每3个月1次。对于CDFI有异常发现者，予严密监视，并行CT门静脉成像证实。对诊断明确的门静脉狭窄患者早期进行介入治疗。结果504例肝移植中，共发生门静脉供血障碍性并发症12例（2．38%），其中单纯吻合口狭窄9例（1．78％）、吻合口狭窄并局部血栓形成2例（0．40％）、门静脉系统广泛血栓形成1例（0．20％），均经积极治疗后痊愈出院。结论肝移植术后采用CDFI技术的跟踪检查对于早期发现门静脉供血障碍性并发症具有重要意义，CT血管成像具有确诊价值。门静脉狭窄的早期介入治疗是安全、有效的；广泛血栓形成者应尽早行2次肝移植治疗。     

肝炎肝硬化病人脾切除术后门静脉血栓形成的相关因素分析

目的 分析肝炎肝硬化门静脉高压症病人脾切除术后门静脉系统血栓形成的相关因素.方法 我院2000年8月至2007年6月共为226例肝炎肝硬化门静脉高压症病人施行了脾切除或脾切除加断流术.本文对其中154例进行回顾性分析.根据是否形成血栓将病例分为门静脉系统血栓形成和无血栓形成两组.用Logistic回归分析术前术后门静脉压力下降水平、术前凝血酶原比值(PTR)、术前纤维蛋白原水平(FIB)、术前及术后1、7、14 d血小板水平、术前门静脉直径、术前胆红素水平、术中出血量各指标与门静脉系统血栓形成的关系.结果 在154例病人中,门静脉系统血栓形成31例,123例无血栓形成.Logistic单因素分析和多因素回归分析均显示门静脉系统血栓形成与门静脉压力下降水平有关;术前凝血酶原比值(PTR)、术前纤维蛋白原水平(FIB)、术前及术后1、7、14 d血小板水平、术前门静脉直径、术前胆红素、术中出血量水平与门静脉血栓形成无关.结论 术前、术后门静脉压力下降水平可能是影响门脉高压脾切除术后门脉系统血栓形成的重要因素,术后门静脉压力下降越多,门静脉系统血栓形成几率越高.     

脾切除术后门静脉系统血栓形成的相关因素分析及早期抗凝效果分析

目的探讨门静脉高压行脾切除术后门静脉系统血栓形成（portalveinthrombosis,PVT）的相关因素,及早期抗凝治疗的预防作用。方法回顾分析102例门静脉高压行脾切除术患者临床资料．观察性别、年龄、术前肝功能Child—Paph分级、门静脉直径、术前和术后2周血小板计数、联合贲门周围血管离断术、抗凝等临床指标与PVT形成的相关性。结果102例患者脾切除术后PVT发生率16．7％（17例）,其中抗凝患者PVT发生率9．1％（5／55）,低于未抗凝治疗患者的25．5％（12／47）,差异有统计学意义（X^2=4．932,P〈0．05）。单因素分析显示PVT组与无PVT组贲门周围血管离断术（64．7％与36．5％）、门静脉内径[（13．8±2．1）mm与（15．2±2．2）mm]和抗凝治疗（29．4％与58．8％）存在统计学差异（P〈0．05）。多因素分析显示门静脉内径（OR=2．448,P=0．029）及是否抗凝治疗（OR=1．610,P=0．032）与术后PVT形成有关。结论脾切除术后PVT形成与门静脉内径增宽、是否抗凝治疗有关。术后早期给予低分子肝素抗凝治疗能降低PVT发生率。     

Biliary injury after laparoscopic cholecystectomy: end-to-end anastomosis covered with umbilical vein

The management of biliary injuries after laparoscopic surgery presents a surgical challenge. We describe a promising method of biliary reconstruction with umbilical vein covering followed by end-to-end anastomosis. In the patient reported here, the umbilical vein was identified in the pedicled ligamentum teres, transected as if it were a sheet, and sutured, then covered ventrally to the anastomosed bile duct. This procedure may be a promising reinforcement of the reconstructed site which maintains the biliary integrity; however, it can be applied, only in selected situations.     

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目的 总结７例胰十二发除术中门静脉损伤临床处理经验。方法 对７例十二指肠切除术中门静脉损伤的病人进行分析。结果 ７例病人中５例恢复良好,切口感染１例。结论 加强胰十二指肠切除术中门静脉损伤的预防,根据不同情况正确修复,严格掌握门静脉血流阻断时限等是直接影响手术效果的关键环节。     

腹腔镜胆囊切除术术中医源性胆管损伤的防治策略

目的:探讨腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)术中减少胆管损伤的策略,以提高手术安全性。方法:回顾分析2003年6月至2008年6月我院行LC286例患者的临床资料。结果:278例成功完成手术,中转开腹8例,占2.80%。平均手术时间(60±30)min,术后第2天下床活动,并开始进食。发生胆漏1例;胆管损伤2例,约占0.70%,1例术中发现,经手术治疗痊愈,另1例转入上级医院,余无其他严重并发症发生。结论:胆管损伤的预防重于治疗,只有掌握扎实的解剖知识、熟练的腹腔镜技术和适时的中转开腹,才能不断减少胆道损伤。     

淤血预处理减轻兔肝门静脉阻断模型中肠道淤血-再灌注损伤

目的 观察淤血预处理对兔肝门静脉阻断模型中肠道淤血-再灌注引起的肠道损伤和肝脏损伤的影响。
方法 选取雄性日本大耳兔75只,体重2.5～5.0 kg,随机分为五组：假手术组（S组）、淤血-再灌注组（OC组）、预处理A组（OC5组）、预处理B组（OC10组）、预处理C组（OC15组）,每组15只。S组仅行剖腹手术暴露第一肝门30 min,OC组进行门静脉阻断30 min后开放门静脉。三个预处理组门静脉操作分别为OC5组夹闭5 min,开放5 min;OC10组夹闭10 min,开放10 min;OC15组夹闭15 min,开放15 min,随后阻断门静脉30 min后开放。术后2、8、24 h通过门静脉取血,检测血清中丙二醛（MDA）含量和内毒素、肿瘤坏死因子-α（TNF-α）、丙氨酸转氨酶（ALT）浓度。术后24 h血液样本采集完毕后,再次麻醉并处死以获取回肠末端肠黏膜及肝组织,显微镜下观察病理形态学结构改变。
结果 与S组比较,术后2、8、24 h OC组、OC5组、OC10组和OC15组血清MDA含量、内毒素、TNF-α、ALT浓度明显升高（P＜0.05）。与OC组比较,术后2、8、24 h OC5组、OC10组和OC15组血清MDA含量、内毒素、TNF-α、ALT浓度明显降低（P＜0.05）。与OC5组比较,术后2、8、24 h OC10组血清MDA含量、TNF-α、ALT浓度明显降低（P＜0.05）。与OC5组比较,术后2、8 h OC10组血清内毒素浓度明显降低（P＜0.05）。与OC10组比较,术后8 h OC15组血清MDA含量、ALT浓度明显升高（P＜0.05）。与S组比较,OC组、OC5组、OC10组和OC15组肠黏膜损伤Chiu评分明显升高（P＜0.05）。与OC组比较,OC5组、OC10组和OC15组黏膜损伤Chiu评分明显降低（P＜0.05）。与OC5组比较,OC10组、OC15组的肠黏膜损伤Chiu评分明显降低（P＜0.05）。
结论 淤血预处理可以减轻由于肝门静脉阻断导致的肠道淤血-再灌注损伤,减轻内毒素血症、过度炎性反应及氧自由基对肝脏的损伤。     

Laparoscopic cholecystectomy in patients with bilharzial portal hypertension.

OBJECTIVE: The purpose of this study was to evaluate the results of laparoscopic cholecystectomy in patients with bilharzial portal hypertension. METHODS: Patients who had gallstones and bilharzia had ultrasonographic assessment of peri-portal fibrosis, endoscopy, hemagglutination and rectal snip. Operating time, blood loss, hospital stay, time of return to work and operative mortality were recorded. Follow-up was two weeks, six weeks and six months after discharge. RESULTS: Twenty-five out of 450 patients, who had laparoscopic cholecystectomy, suffered from bilharzial portal hypertension. Ten patients had grade 1 varices, 10 had grade 2 varices, and 5 had grade 3 esophageal varices. All patients had varying degrees of peri-portal fibrosis as shown by ultrasound. Rectal snip showed schistosoma mansoni in 5 patients, and a hemagglutination test was positive in all. Two patients had conversion to open cholecystectomy. Mean operating time was 1 hour and 15 minutes. Average blood loss was 50 cc. Mean hospital stay for 23 patients was 48 hours. Average time of return to work was 2 weeks in 23 patients and 6 weeks in the 2 patients who had conversion. Twenty-two patients benefited from the operation. There was no mortality in this series. CONCLUSIONS: Laparoscopic cholecystectomy in patients with bilharzial portal hypertension is feasible and has low morbidity.