脾功能亢进与血脾屏障的研究

目的 研究脾功能亢进时血脾屏障的改变,探讨两者的相关性和脾功能亢进的发病机理.方法 收集33例肝硬化门静脉高压脾脏为试验组,20例外伤脾脏为对照组.每例脾脏选取5块组织,HE染色后计数生发中心,总生发中心数量一平均值×脾质量.统计脾脏质量,术前血常规数值.统计学计算生发中心数量与血常规数值的相关性.结果 两组比较,试验组中血常规数值显著降低,脾质量增加(平均值764.2 g),生发中心增多(平均值8817/例).生发中心的总量与血小板计数呈负相关.说明脾功能亢进程度(包括血小板和脾质量)与生发中心数量的关系.即血小板数量越少,其脾脏生发中心的总数越多,脾质量越重,生发中心数量亦越多.结论 肝硬化脾功能亢进时,脾脏中的生发中心显著增多,形态不完整,血脾屏障功能异常.血脾屏障功能异常是脾功能亢进的发病基础.     

原位肝移植术后脾功能亢进的恢复

摘要：目的 观察原位肝移植术后脾功能亢进（脾亢）的变化，探讨肝移植对脾亢的影响。 方法 收集2年半内接受肝移植手术、符合入选条件的14例患者的资料，分析手术前后各时点的脾脏厚度，血小板（PLT）和白细胞（WBC）计数， 以及术后门静脉流速的变化规律。 结果 术后血WBC和PLT计数1个月内恢复正常，脾脏厚度术后1个月下降约17%，此后1年内保持稳定；门静脉流速1个月内明显升高，以后逐步缓慢下降；血WBC，PLT，术后门静脉流速等3个指标和脾脏厚度均具有明显相关性。 结论 术后门静脉的高流速归因于脾静脉回流的持续增高；术前WBC和PLT减少的主要原因是脾脏体积的增大；术后脾亢的恢复取决于脾脏体积的回复程度。脾亢患者行肝移植手术时无需行脾脏切除术。     

合并脾功能亢进肝癌患者的外科治疗

目的 探讨肝癌切除合并脾脏切除对肝癌合并脾功能亢进患者的临床意义.方法 回顾性分析2004年3月至2006年1月我科收治的35例合并脾功能亢进肝癌患者的临床资料,其中切脾组12例,未切脾组23例.分析手术前后肝功能以及血小板、白细胞变化情况.结果 35例均成功切除肿瘤.切脾组12例患者术后脾功能亢进消失.术后1周,切脾组患者白细胞由术前的(3.2±1.7)×109/L上升到(8.5±5.3)×109/L,血小板计数由(52.6±23.7)×109/L上升到(245.3士94.6)×109/L(P＜0.01).未切脾组白细胞及血小板计数变化不大.切脾组肝脏功能恢复较快,术后1周基本恢复至术前水平.切脾组患者均接受了较为系统的术后化疗.术后随访2年,切脾组7例生存(58.3％);未切脾组10例生存(43.5％).切脾组与未切脾组患者总的无瘤生存期分别为(16.4±4.3)个月和(14.3士5.2)个月(P＜0.005).结论 肝癌切除合并脾脏切除是治疗合并脾功能亢进肝癌患者的有效方法.     

远端脾肾分流术联合脾部分切除治疗门静脉高压症脾功能亢进疗效探讨

目的 对比研究远端脾肾分流术（Warren术）与远端脾肾分流术联合脾部分切除治疗门静脉高压症脾功能亢进的疗效。方法 选取第四军医大学唐都医院2010年以来22例获得完整随访资料的行外科手术治疗的门静脉高压症脾功能亢进病人,其中Warren术组（分流组）8例,Warren术+脾部分切除组（分流+切脾组）14例,比较观察两组术前、术后第7、30天的外周血象主要指标（白细胞、血小板）以及两组术前、术后第30天外周血免疫指标（IgG、 IgA 、IgM）。结果 Warren术+脾部分切除组病人术后白细胞及血小板恢复指标明显优于Warren术组,差异有统计学意义（P<0.05）;外周血免疫球蛋白检测显示两组术后与术前比较差异无统计学意义（P>0.05）。结论 Warren术联合脾部分切除治疗门静脉高压症脾功能亢进疗效优于单纯Warren术。在有效降低门静脉压力前提下很大程度上解决脾功能亢进,又保留了脾脏正常免疫功能。但切除脾脏比例以及适应证等需根据病人制定个体化治疗方案,尤其在切除脾脏比例方面需要进一步研究验证。     

门静脉高压症原位肝移植前后内脏血流动力学变化的临床研究

目的 研究门静脉高压症原位肝移植前后内脏血流动力学变化及其对脾功能亢进、侧支循环、术后肝功能恢复的影响.方法 2002年6月至2005年10月上海交通大学医学院附属瑞金医院外科共完成173例原位肝移植术.选取其中38例肝硬化门静脉高压症患者,分别于术前、术后1、3、5、7 d、1个月、6个月、1、2、3年行彩色多普勒超声检查,监测患者门静脉血流平均速度、门静脉血流量、肝动脉阻力指数等血流动力学指标和脾脏大小变化,并与8例急性重症肝炎患者及20名健康人进行对照,同时观察其对肝功能和食管胃底曲张静脉的影响.结果 肝硬化门静脉高压症患者术后门静脉血流平均速度从术前(13.7±4.2)cm/s升至(58.4±25.2)cm/s,门静脉血流量从(958±445)ml/min升至(3024±1207)ml/min,肝动脉阻力指数从0.65±0.11升至0.74±0.12,均明显高于急性重症肝炎组和正常对照组(P<0.05),门静脉血流平均速度和门静脉血流量分别于术后6个月、2年降至正常对照组水平.肝硬化门静脉高压症组术后脾功能亢进从术后第2天开始改善,至术后1个月完全恢复,但脾脏肿大在术后3年仍然存在.术后食管胃底曲张静脉亦明显改善.结论 肝硬化门静脉高压症患者原位肝移植术后内脏高血流动力学仍将长期存在,但并不影响脾功能亢进和食管胃底静脉曲张以及肝功能的恢复.     

肝癌合并门静脉高压术中脾动脉结扎的临床疗效观察

目的探讨肝癌切除术中行脾动脉结扎治疗肝癌合并门静脉高压的临床疗效。方法回顾性分析2008年1月至2013年1月收治的肝癌合并门静脉高压患者临床资料和手术疗效,对照组患者共33例仅进行肝癌切除术,试验组患者共38例于肝癌切除术中行脾脏动脉结扎。采用SPSS16.0统计软件,对两组患者术前术后1~3个月门静脉压力、血常规检测、脾静脉血流流量等上述指标以x珋±s表示,采用t检验,P<0.05表示差异有统计学意义。结果术后1、2、3个月血象(血细胞三系)和脾静脉血流数值:试验组患者红细胞数、白细胞数、血小板数显著高于对照组(t值分别为:3.457、2.876、2.987;2.975、3.112、2.986;2.964、3.587、3.457。P<0.05),试验组患者脾静脉血流显著低于对照组(t值分别为:2.991、2.989、2.891,P<0.05),两组差异有统计学意义,结果提示脾动脉结扎在短期(4个月)内可明显改善肝硬化所致门静脉高压-脾功能亢进状况。术后4个月,两组患者红细胞数、白细胞数、血小板数及脾静脉血流量比较无明显差异P>0.05。结论肝癌切除术中行脾动脉结扎治疗肝癌合并门静脉高压短期内可有效缓解肝硬化所致门静脉高压-脾功能亢进状况。     

终末期肝病患者切脾与否对肝移植后血小板的影响

目的探讨脾切除对终末期肝病患者肝移植后血小板的影响。方法为52例终末期肝病患者施行肝移植,其中16例术前已切除脾脏(既往切脾组),9例肝移植的同时切除脾脏(术中切脾组),27例保留脾脏(保留脾脏组),比较三个组手术前后血小板数的变化。结果既往切脾组肝移植前有2例(12.5%)存在门静脉栓塞,术中切脾组有1例(11.1%)术后发生门静脉栓塞。既往切脾组术前血小板数明显高于术中切脾组和保留脾脏组(P<0.05);术后第1、3天,既往切脾组血小板计数明显高于保留脾脏组(P<0.05);术后第5天,术中切脾组血小板计数明显高于保留脾脏组(P< 0.05);术后第7、14、30天,三组间血小板计数两两比较,差异均无统计学意义。结论终末期肝病患者切脾与否对肝移植后血小板的影响是短暂的,原则上肝移植同期不行脾切除。     

肝硬化门静脉高压症患者肝移植术后门静脉血流动力学变化的临床研究

目的探讨肝硬化门静脉高压症患者肝移植术后早期门静脉系统血流动力学变化规律。方法应用彩色多普勒B超检测50例行原位肝移植术的肝硬化患者及24例正常对照的门静脉、脾静脉的直径、流速,脾脏的体积;应用压力传感器检测患者肝移植术中门静脉压力变化情况。结果肝移植术后门静脉直径变小,流速增高,流量增大,在观察期内持续高于正常对照。脾静脉流量增加不明显(g=3．21,P＞0．05)。门静脉压力由开腹时的(24．57±6．22)mm Hg降至关腹前的(16．81±5．03)mm Hg,仍稍高于正常值,降压效果明显,降幅达31．7%。术后静脉曲张情况明显改善。脾功能亢进在术后亦得到明显缓解,外周血中自细胞及血小板在短期内恢复正常(t=2．89,P＜0．05)。结论与术前相比,肝移植术后门静脉系统呈现高流速、高流量状态,短期内难以恢复。脾功能亢进得到明显缓解。门静脉压力在新肝植入2～4 h后较术前明显下降,接近正常水平。     

原位肝移植后门脉高压和脾功能亢进的恢复过程

采用全血细胞计数监测和彩色多普勒超声断层的方法对两例因肝硬化合并门脉高压脾功能亢进而行同种异体原位肝移植术的患者进行了临床观察。全血细胞计数监测显示；与术前相比，红细胞计数在术后一个月之内未见明显改善，一个月之后逐渐恢复近于正常。术后１３天白细胞计数和血小板计数恢复至正常范围。     

脾动脉结扎联合贲门周围血管离断术治疗门静脉高压症脾功能亢进

目的探讨脾动脉结扎联合贲门周围血管离断术治疗门静脉高压症脾功能亢进的安全性和有效性。方法2012年2月至2014年1月前瞻性研究对比脾动脉结扎和脾切除联合贲门周围血管离断术治疗42例脾功能亢进患者的疗效。结果术前两组白细胞计数、血小板计数、白蛋白计数、总胆红素、凝血酶原时间、平均年龄和术中平均出血量差异均无统计学意义。术后两组白细胞计数和血小板计数均有改善,脾动脉结扎组上升速度相对平缓;术后门静脉压力下降程度类似;脾动脉结扎组门静脉系统血栓形成概率小于脾切除组（4／19与11／23,P〈0．05）,脾动脉结扎组出现3例局灶性脾梗死,经保守治疗后均好转。两组均无死亡病例。结论脾动脉结扎联合贲门周围血管离断术可以作为脾功能亢进的一种安全有效的治疗手段,但其长期效果仍有待进一步观察。     

Radiofrequency ablation for hypersplenism in patients with liver cirrhosis: A pilot study

Radiofrequency ablation is a relatively new technique used for local ablation of unresectable tumors. We investigated the feasibility and eficacy of radiofrequency ablation for hypersplenism and its effect on liver function in patients with liver cirrhosis and portal hypertension. Nine consecutive patients with hypersplenism due to cirrhotic portal hypertension underwent radiofrequency ablation in enlarged spleens. The ablation was performed either intraoperatively or percutaneously. Patients are followed up for over 12 months. After treatment, between 20% and 43% of spleen volume was ablated, and spleen volume increased by 4%–10.2%. White blood cell count, platelet count, liver function, and hepatic artery blood flow showed significant improvement after 1-year follow-up. Splenic vein and portal vein blood flow were significantly reduced. Only minor complications including hydrothorax (three of nine patients) and mild abdominal pain (four of nine patients) were observed. No mortality or other morbidity occurred. Radiofrequency ablation is a safe, effective, and minimally invasive approach for the management of splenomegaly and hypersplenism in patients with liver cirrhosis and portal hypertension. Increased hepatic artery blood flow may be responsible for sustained improvement of liver condition. Radiofrequency ablation may be used as a bridging therapy for cirrhotic patients waiting for liver transplantation.     

Predictive factors for persistent splenomegaly and hypersplenism after adult living donor liver transplantation

Purpose

The aim of this study was to evaluate predictive factors for persistent splenomegaly and hypersplenism after living donor liver transplantation (LDLT).

Patients and methods

From January 2008 to June 2010, 159 adult patients (116 males and 43 females) who underwent living donor liver transplantation (LDLT) had pre- and post-LDLT computed tomography angiography and survived more than 6 months. Patients with post-LDLT portal vein stenosis were excluded from this study. We analyzed the impact for persistent splenomegaly and hypersplenism after LDLT of pre-LDLT spleen volume, main portal vein (PV) size, coronary vein (CV) size and platelet levels.

Results

While 38 patients displayed splenomegaly, 121 showed normal spleen volumes at 6 months after LDLT (LDLT). There were 119 thrombocytopenic versus 40 normal platelet patients at 6 months post-LDLT. The persistent splenomegaly patients showed significantly larger pre-LDLT spleen volume, larger PV and CV sizes as well as lower platelet levels before (×10,000/mL) and 1 month after LDLT (×10,000/mL). Multiple logistic regression analysis showed spleen volume and platelet count at 1 month posttransplant to be the only variables associated with persistent splenomegaly at 6 months post. Persistent thrombocytopenia at 6 months post-LDLT was associated with significantly larger pre-LDLT spleen volume, larger CV size, and lower platelet levels including P0 and P1 m. Multiple logistic regression analysis showed that platelet count at 1 week and at 1 month post-LDLT were the variables associated with persistent thrombocytopenia at 6 months post-LDLT.

Conclusion

Spleen volume and platelet levels at 1 month after LDLT may predict persistent splenomegaly at 6 months post-LDLT. The predictive factors for hypersplenism at 6 months post-LDLT may be platelet levels at 1 week and at 1 month post-LDLT.     

Platelet aggregability after splenectomy in patients with normosplenism and hypersplenism

The relationship between platelet count and aggregability was serially evaluated after splenectomy in patients with normosplenism and hypersplenism, and the results were compared with those found in patients undergoing only upper abdominal surgery. The preoperative count and aggregability of platelets were significantly suppressed in patients with cirrhosis of the liver, idiopathic portal hypertension, and prehepatic portal obstruction. However, the platelet aggregability of these patients markedly increased in accordance with the platelet counts after splenectomy. In the patients with normal splenic function preoperatively, splenectomy caused a simultaneous increase in platelet count and aggregability. The platelet function was not always reflected by the count in the patients with idiopathic thrombocytopenic purpura. On the other hand, in the control patients undergoing only laparatomy the platelet count substantially increased two weeks after operation, but platelet aggregability did not differ from the preoperative value. The present results suggest that additional factors for thromboembolism such as hypotension, acidosis, or stagnant blood flow should be avoided during the peak period of reactive thrombocytosis after splenectomy, and that an appropriate use of anticoagulants or inhibitors of platelet aggregation is recommended if and when necessary.     

Reversal of hypersplenism following orthotopic liver transplantation.

The purpose of this study was to clarify the effect of orthotopic liver transplantation on hypersplenism. In a 1-year period from July 1, 1986 to June 30, 1987, 196 adult patients underwent 233 orthotopic liver transplantations. Of the 58 patients with hypersplenism who were analyzed in this study, hypersplenism was more commonly associated with postnecrotic cirrhosis than other kinds of liver disease (55.3% (47/85) vs. 14.5% (11/76); p less than 0.001). Postoperative platelet counts were statistically higher than preoperative values (p less than 0.05). The latest platelet counts were more than 100,000/mm3 in 53 patients (91.4%). Of the eight patients whose preoperative and postoperative spleen volumes could be compared, all showed the reduction in the spleen size (p less than 0.02). We conclude that orthotopic liver transplantation, which is a radical surgical procedure for portal hypertension, reverses hypersplenism.     

部分脾动脉栓塞术治疗肝硬化门静脉高压症的临床疗效分析

目的探讨部分脾动脉栓塞术（PSE）治疗肝硬化门静脉高压症的临床疗效。方法选取我院62例肝硬化食管胃底静脉曲张破裂出血和脾功能亢进患者。全组均行PSE,观察手术前后外周血象变化,门静脉、脾静脉管径变化及术后并发症发生情况。结果PSE术后白细胞、血小板计数高于术前（P〈0．05）;门静脉、脾静脉管径较术前缩小（P〈0．05）,全组病例无严重并发症发生。结论PSE治疗肝硬化并脾功能亢进操作简便、创伤较小、疗效稳固,可以抢救和预防再出血,尤适用于高危病重、老年不适于手术治疗者,是值得临床推广和应用的手术方法。     

Partial splenic embolization in patients with liver cirrhosis and hepatocellular carcinoma: Effects on portal hemodynamics

Partial splenic embolization (PSE) was performed on patients with liver cirrhosis to control hypersplenism and gastroesophageal varices. In this study, we evaluated the effects of PSE on the portal hemodynamics and hepatic function of 17 cirrhotic patients with hepatocellular carcinoma. The mean splenic volume and the peak platelet count increased significantly and the splenic vein pressure decreased significantly after PSE. However, the portal blood flow did not change. Changes in the 15-min retention rate of indocyanine green and the arterial ketone body ratio were not significant, but the redox tolerance index increased from 0.24 ± 0.28 × 10^–2 to 0.59 ± 0.35 × 10^–2. These results suggest that PSE may reduce perioperative risks in cirrhotic patients with hepatocellular carcinoma who are candidates for hepatic resection.     

脾切除对肝硬化门静脉高压脾功能亢进患者影响的研究进展

肝炎后肝硬化通常合并门静脉高压症,后者常致脾功能亢进(脾亢).对于同时伴有脾亢的患者,是否联合行脾脏切除,目前尚存在争议.持保脾观点的一方认为,脾切除后会降低免疫功能,增加感染机会和肝肿瘤的发生,同时会增加门静脉系统并发血栓的风险.而主张切脾的一方认为,联合脾切除作为外科治疗门脉高压症的主要方法之一,除了能降低门静脉压...