Ƣ��������������Ѫ�ܷ�����7������

目的 探讨脾肾静脉间置人造血管分流术治疗门静脉高压症的可行性。方法 自１９９９年１～１２月施行脾肾静间置人造血管（ＰＴＦＥ）的脾肾静脉分流术治疗门静脉高压７例并进行随访。结果 分流后门脉压力平均下降１．２７ｋＰａ,无并发症及手术死亡。随访５～１２个月,彩超示间置人造血管管通畅,食道吞钡显示食道静脉曲张改善４例,消失３例。无再出血,无肝性脑病。结论 该术式治疗门静脉高压症较传统手术简单安全,疗效确切     

改良式断流术联合脾肾分流术治疗门静脉高压上消化道出血的疗效评价

目的研究改良式断流术和联合脾肾分流术对门静脉高压症的治疗效果。方法收集2005年9月至2010年5月福建医科大学附属第二医院收治的46例肝硬化门静脉高压上消化道出血患者的临床和随访资料,根据术式分为联合组（改良式断流术联合脾肾分流术,24例）和断流组（改良式断流术,22例）进行生存分析。结果两组治疗前临床基础资料具有可比性。治疗后断流组自由门静脉压力（FPP）为（37．1±9．7）cmH2O,高于联合组的（30．1±8．9）cmH,O（P〈0．05）;联合组门静脉高乐性胃病、上消化道再出血及门静脉系统血栓的发生率明显低于断流组（均P〈0．05）,而肝性脑病发生率差异无统计学意义。结论改良式断流术联合脾。肾分流术治疗门静脉高压上消化道出血的疗效优于单纯改良式断流术。     

门体分流术在肝硬化门静脉高压症外科治疗中的地位

传统外科手术是我国目前治疗肝硬化食管胃底静脉曲张出血的主流手术,虽然手术方式繁多,但不能违背依据门静脉血流动力学状况进行术式选择的原则。如果门静脉压力升高的主要原因是肝内阻力增加所致,只有门体分流术才能取得满意的降压和止血效果,因此门体分流术在肝硬化门静脉高压症外科治疗中仍占据重要地位,适合于肝硬化食管胃底静脉曲张破裂出血、门静脉高压性胃病出血和断流术后再次出血的患者。在我国,对于内镜治疗失败的患者,门体分流术也是主要的治疗手段。在各种分流加断流的联合手术中,脾切除脾肾静脉分流加贲门周围血管离断术最合理,应成为首选。     

门静脉高压症食管胃底曲张静脉的经腹断流和栓塞术

食管、胃底静脉曲张是肝硬变门静脉高压症的一种危险并发症。曲张静脉一旦破裂出血,半数病例可因此死亡,且不论用何种方法止血。由于肝硬变难以逆转,患者在术后不仅有再出血的危险,另一部分患者还终将死于肝功能衰竭。 治疗食管、胃底静脉曲张/出血的方法有多种,但就其治疗原则而论不外三类:一类手术是在门静脉系统与体静脉之间作各种分流术,如脾肾、脾腔、     

保脾断流术治疗门静脉高压症食管胃底静脉曲张破裂出血的远期疗效观察

目的探讨保脾断流术治疗门静脉高压症食管胃底静脉曲张破裂出血的远期疗效。方法对我院2008~2013年期间所行的保脾断流术患者进行门诊或者电话随访,观察食管胃底静脉曲张缓解、再出血、生存情况及术后远期并发症。结果共完成保脾断流术治疗门静脉高压症食管胃底静脉曲张破裂出血患者32例,围手术期死亡1例。23例患者获得随访,平均随访时间45.5个月(10~81个月),随访期内有7例发生术后再出血,5例死亡,3例新发门静脉血栓,2例发生食管吻合口狭窄。结论保脾断流术在特定的患者中,是一种有效的治疗门静脉高压症食管胃底静脉曲张破裂出血的术式。     

门静脉高压症治疗的50年回顾

目的：探讨门静脉高压症的外科治疗。方法：我院50年共收治门静脉高压症939例，分别行脾切除236例，脾腔分流术151例，脾切除＋肠系膜上静脉上静脉下腔静脉吻合术71例，脾肾静脉吻合术42例，肠系膜下静脉下腔静脉吻合术2例，贲门胃底血管离断术409例，胃底曲张静脉和部分脾介入栓塞术28例。术后随访2年、5年，并行上消化道钡餐透视。结果：比较脾腔分流术、贲门胃底血管离断术及胃底曲张静脉和部分脾介入栓塞术的远期效果：脾腔分流术的2年、5年绝对生存率分别为81．6％、56．1％，再出血率4．3％。贲门周围胃底血管离断术的2年绝对生存率为78．7％，再出血率8．0％；5年绝对生存率为74．8％，再出血率为12．4％。胃底曲张静脉和部分脾介入栓塞术的即时止血效果达到100％，术后2年再出血率为率28．6％，死亡率14．3％，术后5年生存率为14．3％。结论：Child分级B级，特别是已发生过大出血的病人，可选择贲门周围胃底血管离断术。ChildC级、有严重黄疸、腹水，发生大出血不宜手术治疗的病人，可行介入曲张血管栓塞术治疗。     

门静脉高压症外科治疗185例

目的探讨门静脉高压症的外科治疗一方法回顾分析我科近10年收治的门静脉高压症共185例，分别行单纯脾切除21例，脾切除、贲门周围血管离断加胃底黏膜下环扎术107例．门腔分流术29例，脾肾分流加贲门周围血管离断术和胃底环扎术18例，肝移植术10例。术后随访1～6年：结果单纯脾切除术的再出血率为14.3％，生存率为85．7％。贲门周围血管离断加胃底黏膜下环扎术的再出血率为10．4％，生存率为78．5％。门腔分流术无再出血病例．生存率为93％。脾肾分流加贲门周围血管离断术和胃底黏膜下环扎术的再出血率为11．1％，生存率为89％。肝移植术随诊1～5年，存活8例。结论门静脉高压症的外科治疗应根据患者的不同情况采取不同的手术方法。     

选择性脾肾静脉分流术(文献综述)

自1945年 Whipple Blakemore 等倡用门腔静脉分流术治疗肝硬变门静脉高压症引起的食管、胃底静脉曲张破裂出血以来,迄今已发展为两种类型的分流术:一类为门静脉主干分流术,包括门腔静脉分流术、脾肾静脉分流术、及肠系膜上静脉与下腔静脉分流术等。这类手术都是通过分流门静脉主干的血液到低压的下腔静脉系统的方法来降低门静脉压力,从而达到止血目的,可称为总体分流     

门-奇静脉断流加脾切除术治疗门静脉高压症95例报告

目的 探讨门-奇静脉断流加脾切除术对肝硬化、门静脉高压症导致食管、胃底静脉曲张的治疗效果。方法 回顾性分析95例门-奇静脉断流加脾切除术的临床资料;全组男68例,女27例,均为肝炎后肝硬化,门静脉高压,食管、胃底静脉曲张病例,全部均有脾功能亢进表现,肝功能Child A级62例,Child B级33例。施行Hassab断流加脾切除术29例,施行改良Sugiura式门-奇断流加脾切除术41例,施行选择性改良Sugiura式门-奇断流加脾切除术25例。结果 全组术后均检出白血球升高,血小板计数超300×109/L 25例,术后平稳恢复83例;肝功能明显减退、大量腹水、少尿12例,轻度黄疸2例,经积极治疗全部康复出院。85例（89.5%）得到1～3年随访,在29例Hassab手术中6例再出血（20.6%）;41例改良Sugiura手术中5例再出血（12.19%）,2例为食管静脉曲张出血,3例为门脉高压性胃病引起;25例选择性改良Sugiura手术均无再出血表现。结论 选择性改良Sugiura门-奇静脉断流加脾切除术是现代治疗门静脉高压、食管胃底静脉曲张急性出血的有效手术,在三种断流术中具有合理性和优越性。     

门静脉高压症术后再出血外科治疗的探讨（附65例临床分析）

目的：探讨门脉高压症术后再出血外科治疗手术方式的选择。方法：回顾性分析总结65例门脉高压症术后再出血的治疗情况。结果：47例采用了不同术式的外科治疗,其中行肠腔侧侧分流术29例,肠系膜下静脉腔静脉分．流术6例,肠系膜上静脉属支腔静脉分流术4例,肠系膜上静脉属支左肾静脉分流术2例,断流术6例,手术死亡5例,结论：外科治疗目前仍是治疗门脉高压症术后再出血的主要手段,且以择期手术为宜,其中肠腔侧侧分流术是断流术后再出血治疗的首选术式,选择性分流术（DSRS,DSCS）术后再出血的外科治疗主要采用脾切除加断流术,当肠腔分流术后再出血时,行肠系膜下静脉左肾静脉分流术或肠系膜上静脉属支腔静脉分流术是可行的,手术创伤小,疗效较好。     

Portal diversion for portal hypertension in children. The first ninety patients.

Ninety children with portal hypertension were treated by portal diversion. Fifty-two had cavernous transformation of the portal vein and 38 had an intrahepatic block from various causes. There were 59 central splenorenal shunts, 19 mesocaval, 11 portacaval and one distal splenorenal. In 61 peripheral shunts the veins used for the anastomosis were less than 10 mm in diameter. There was no operative mortality in children with extrahepatic block. One child with cystic fibrosis died postoperatively. Thrombosis of the shunt occurred in five children (5.6 per cent) and was responsible for recurrent bleeding in two. Four children with a thrombosed shunt underwent succesful reoperation and one is awaiting another anastomosis. No late complications occurred in the 52 children with extrahepatic block, while encephalopathy developed in four children with intrahepatic block. These figures confirm our earlier results in the management of portal hypertension in childhood and suggest that portal diversion is the treatment of choice. Several precautions have permitted lowering of the rate of thrombosis whichever shunt is performed. Portal diversion should be indicated following the first episode of hemorrhage in children with extrahepatic block. In patients with intrahepatic block, congenital hepatic fibrosis and cystic fibrosis are good indications as are in general the hepatic diseases with no or mild activity.     

改良式断流术加脾肾分流治疗门静脉高压症上消化道出血22例分析

目的探讨改良式断流术加脾肾分流术联合治疗门静脉高压症上消化道出血的临床效果。方法对22例采用改良式断流术加脾肾分流术(联合组),并与20例改良式断流术(断流组)比较术前肝功能、术中测定自由门静脉压、术后14~21 d色多普勒超声检测门静脉血流速度、吻合口情况的回顾性分析。结果联合组无手术死亡、再出血及肝性脑病发生,联合组术后18个月因肺炎死亡1例,断流组术后35个月出血3例,术后1,3年生存率100%及95.5%。结论改良式断流术加脾肾分流术,既保留了幽门收缩功能及断流术的优点,又降低了门静脉压力,并能保持一定量的向肝血流量,有利于肝功能的恢复及腹水的消失。     

Assessment of portosystemic shunt patency and function with magnetic resonance imaging

Magnetic resonance imaging (MRI) was performed in seven patients before and after portosystemic shunting to evaluate venous changes accompanying nonselective and selective shunt construction. The size and number of the intrahepatic portal and hepatic veins, left perirenal veins, and left upper quadrant varices were evaluated at MRI before and after shunt construction. MRI correctly diagnosed patent shunts in all seven patients. A marked decrease in the size of intrahepatic veins after a total or nonselective shunt suggests adequate portal vein and variceal decompression. Dilatation of left perirenal veins in the presence of a patent mesorenal or splenorenal shunt suggests hypertension of the left renal vein and possibly inadequate decompression of esophageal varices.     

Porto-systemic shunt using adrenal vein as a conduit; an alternative procedure for spleno – renal shunt

Background  

Currently, portal hypertension is still big problem for the patients with serious liver diseases. Variceal bleeding is one of the most important complications of portal hypertension. In case of failure of endoscopic and combined medical treatments, surgical decompressive shunts are required. We emphasized an alternative splenorenal shunt procedure using adrenal vein as a conduit.     

Proximal splenorenal shunts for extrahepatic portal venous obstruction in children.

OBJECTIVE: The results of proximal splenorenal shunts done in children with extrahepatic portal venous obstruction were evaluated. SUMMARY BACKGROUND DATA: Extrahepatic portal venous obstruction, a common cause of portal hypertension in children in India, is being treated increasingly by endoscopic sclerotherapy instead of by proximal splenorenal shunt. It is believed that surgery (or the operation) carries high mortality and rebleeding rates and is followed by portosystemic encephalopathy and postsplenectomy sepsis. However, a proximal splenorenal shunt is a definitive procedure that may be more suitable for children, particularly those who have limited access to medical facilities and safe blood transfusion. METHODS: Between 1976 and 1992, the authors performed 160 splenorenal shunts in children. Twenty were emergency procedures for uncontrollable bleeding and 140 were elective procedures--102 for recurrent bleeding and 38 for hypersplenism. RESULTS: The overall operative mortality rate was 1.9%--10% (3/160-2/20) after emergency operations and 0.7% (1/140) after elective operations. Rebleeding occurred in 17 patients (11%), and pneumococcal meningitis developed in 1 patient who recovered later. Encephalopathy did not develop in any patient. Four patients died in the follow-up period--two of rebleeding, one of chronic renal failure and a subphrenic abscess, and one of unknown causes. The 15-year survival rate by life table analysis was 95%. CONCLUSIONS: A proximal splenorenal shunt, a one-time procedure with a low mortality rate and good long-term results, is an effective treatment for children in India with extrahepatic portal venous obstruction.     

Liver transplantation in patients with previous portasystemic shunt

Over a 9-year period, 58 patients who had previous portasystemic shunt procedures underwent orthotopic liver transplantation (OLTx) under a cyclosporine-steroid immunosuppressive regimen. The types of shunt used were distal splenorenal (18 patients), mesocaval (17 patients), end-to-side portacaval (11 patients), side-to-side portacaval (5 patients) and proximal splenorenal (7 patients). The mean interval between shunt and transplantation was 6 years. There was no statistical difference in survival between patients with previous shunts and the entire population of patients with primary liver transplantation performed during the same period of time. Age, sex, shunt patency, status of portal vein, and use of vein or artery graft did not affect survival. Child's classification had a significant influence on graft survival, even though no difference was subsequently observed in patient survival. A progressively improved intraoperative strategy and the use of veno-venous bypass and University of Wisconsin preservation solution had a significant impact on blood loss, length of operation, length of stay in intensive care unit, and ultimately, on survival. Distal splenorenal and mesocaval shunts with no or minimal hilum dissection are safer shunts if subsequent transplantation is planned; in fact, their 9-year survival was 87%, whereas all other shunts were associated with a survival no better than 52% (p less than 0.006).     

Role of the distal splenorenal shunt in management of variceal bleeding in Latin America

In the early 1970s, we began to perform selective shunts on a regular basis for the treatment of portal hypertension. In a 15-year period, 177 patients (155 with liver cirrhosis) were treated with 3 kinds of selective shunts: the Warren shunt (128 patients) the end-to-end splenorenal shunt (29 patients), and the splenocaval shunt (20 patients). One hundred sixty-seven of the procedures were elective. Operative mortality was 14%, and survival for the Child's class A group was 75% at 1 year, 69% at 5 years, and 65% at 15 years. Incapacitating encephalopathy was observed in 7% of the patients, rebleeding in 6%, and shunt thrombosis in 6%. Postoperative portal vein alterations included reduced venous diameter (13%) and thrombosis (21%). Experience with the Warren shunt in schistosomiasis, a disease in which normal liver function is the rule in Latin American countries, is discussed. We believe that, when feasible, the selective shunts are the treatment of choice for portal hypertension in Latin American countries.     

Cause and management of upper gastrointestinal bleeding after distal splenorenal shunt.

BACKGROUND. The aims of this study were to determine the causes of recurrent upper gastrointestinal hemorrhage (UGH) after distal splenorenal shunting (DSRS) and to summarize our experience in the prevention and management of this complication. METHODS. This study is based on a retrospective review of 145 consecutive patients undergoing DSRS from 1978 through 1991. RESULTS. Recurrent UGH developed in 19 patients (13%), most frequently secondary to residual portal hypertension (84%). Eight patients had shunt thrombosis and 11 had patent shunts. The incidence of shunt thrombosis was significantly greater in patients whose splenic vein was less than or equal to 8 mm in diameter (44%) than those whose splenic vein was greater than 8 mm (7%, p less than 0.001). The frequency of shunt failure from 1985 through 1991 was significantly lower (2%) than from 1978 through 1984 (10%, p less than 0.05). Five patients, all with occluded shunts, underwent surgical treatment for recurrent UGH and three died (60%). Fourteen patients were managed nonoperatively, with a mortality rate of 38%. CONCLUSIONS. Recurrent UGH after DSRS occurs in patients with patent shunts and in those with occluded shunts; DSRS thrombosis is more frequent when the splenic vein diameter is less than or equal to 8 mm; DSRS thrombosis decreases with operative experience; and the mortality rate for this complication is high with both operative and nonoperative management.     

小儿门静脉海绵样变性的诊断及治疗

目的探讨小儿门静脉海绵样变性的临床表现、诊断方法、治疗及预后等问题. 方法 16例门静脉海绵样变性患儿,14例首发症状表现为呕血、便血,2例表现为顽固性贫血,脾脏肿大是其重要体征,均经彩色多普勒获得明确诊断.均行脾切除、食道下端胃底静脉离断术,14例施行了不同方法的分流手术. 结果均获随访,时间平均31/2(8月～7年).彩色多普勒显示分流处血管吻合口通畅,贫血症状明显好转.3例患儿再次出现上消化道大出血症状,经内科保守治疗缓解. 结论该病可能与先天因素有关.诊断主要根据影像学检查,其中彩色多普勒由于无创、可动态观察血流动力学、价格低廉等优点而被列为首选.治疗以手术治疗为主,手术分流可以获得良好的效果.     

Selective distal splenorenal shunt without requiring splenopancreatic disconnection with the use of the external iliac vein graft: a preliminary report.

BACKGROUND: Distal splenorenal shunt (DSRS) with splenopancreatic disconnection (SPD) is an ideal operation for permanent control of variceal bleeding. However, it is a very complicated procedure, and DSRS without SPD has a functional disadvantage: It gradually loses its selectivity and portal blood flow. To overcome these conditions, we designed a new technique--modified DSRS, which is easy to perform and maintains long-term selectivity of the shunt. METHODS: Modified DSRS was performed by using an external iliac vein graft without treating small pancreatic tributaries of the splenic vein. It was applied in 4 cases, and shunt patency and selectivity were examined by angiography during follow-up periods (6-76 months). RESULTS: Modified DSRS was technically more feasible and less complicated than DSRS with SPD. Every attempt was successful. There was no operative mortality, and all the patients were discharged from the hospital in good condition. The shunts were patent in all of them, and the selectivity of the shunt was maintained better in comparison to standard DSRS. CONCLUSIONS: Modified DSRS is a much easier and safer technique than standard DSRS. We consider this procedure to be the best method for surgical management of portal hypertension causing esophageal and gastric varices.