贲门周围血管离断术治疗门脉高压症并发上消化道大出血的疗效分析

本文报道贲门周围血管离断术治疗门脉高压症并发上道大出血３２例。肝功能按Ｃｈｉｌｄ分级，Ａ级７例，Ｂ级１４例，Ｃ级１１例。急症手术２４例（７５％），择期手术８例（２５％）。治疗效果比较满意。急症手术者获得止血２２例（９１．７％）。手术死亡占１２．５％，均为急症手术者。２７例术后获得随访２－１１年，全身状况改善者８２．２％，无肝性脑病发生。作者对影响疗效的有关因素作了探讨。     

Mirizzi综合征的诊断与治疗

为探讨Ｍｉｒｉｚｚｉ综合征的诊断和治疗特点，对３４例经手术证实的Ｍｉｒｉｚｚｉ综合征进行回顾性分析。结果显示：术前确诊仅７例（２０．６％），其中ＥＲＣＰ确诊５例。３４例中行胆囊大部分切除术１２例，胆囊切除术７例，胆囊切除及胆管瘘口缝合修补术６例，胆囊大部分切除及胆囊瓣瘘口修补术４例，胆囊切除及肝总管空肠Ｒｏｕｘ－ｅｎ－Ｙ吻合术５例。２５例获随访，随访时间为１～１４年，其中疗效优１８例（７２％），良５例（２０％），欠佳２例（８％）。提示：Ｂ超结合ＥＲＣＰ检查可以提高Ｍｉｒｉｚｚｉ综合征的术前确诊率，手术方式应根据病理损伤程度决定。     

改良式Sugiura手术治疗门静脉高压的改进

我院１９９６年５月开始，对改良式Ｓｕｇｉｕｒａ手术治疗门静脉高压进行改进，临床应用１８例，并对其中１２例进行随访，效果满意，报告如下。１．临床资料　本术式应用１８例，年龄３２～５３岁；男１２例，女６例。１８例中肝功能Ｃｈｉｌｄ分级：Ａ级１０例，Ｂ级８例。其中１６例有大出血史。１８例中，择期手术１１例。急诊手术７例。２．手术方法　改良Ｓｕｇｉｕｒａ手术的改进方法是经腹完成Ｈａｓｓａｂ手术后，尤其处理好胃后静脉及胃冠状静脉的高位食管支后，用皮钳夹住贲门食管交界处以上５ｃｍ处，固定食管以利操作。在贲门…     

CT检查预测肝癌手术切除安全性的价值

目的 探讨ＣＴ检查预测肝癌手术切除安全性的价值。方法 对６０例肝癌病人进行了肝切除术前与术后肝功能、ＣＴ检查研究。结果：Ｃｈｉｌｄ肝功能分级、ＣＴ检查检查预测肝癌手术切除安全性的符合率分别为５０．０％（Ｐ〈０．０５）、７３．３％（Ｐ〈０．００１）。结论 术前Ｃｈｉｌｄ氏肝功能分级不能准确预测肝癌手术切除的安全性,ＣＴ检查可更有效地预测肝癌手术切除的安全性。     

左主干狭窄的外科治疗

目的 探讨左主干狭窄（ＬＭＳ）≥５０％患者的外科治疗效果。方法 ４２例ＬＭＳ的患者接受了冠状动脉旁路移植术（ＣＡＢＧ）。平均年龄６８．７岁。ＬＭＳ介于５０％￣７５％者１６例,大于７５％者２６例,不稳定型心绞痛２９例。按ＣＣＳＳ标准心绞痛分级,Ⅰ级２例,Ⅱ级５例、Ⅲ级１７例,Ⅳ级１８例。左室射血分数小于５０％者２４例。结果 术前平均住院时间２．３ｄ人均移植血管３．３根,无手术死亡。术后所有患者心绞痛     

胆囊癌临床分析和诊治体会

目的：总结胆囊癌（ＧＢＣ）临床表现、诊断和治疗体会。方法：对我院１９８１～２０００年收治的７２例ＧＢＣ作回顾性分析,其中５７例和２６例病人分别接受Ｂ超或ＣＴ检查,６４例经手术与术后病理证实。结果：本组ＧＢＣ胆囊结石共存率７９．２％（５７／７２）,Ｂ超诊断符合率５４．４％（３１／５７）,ＣＴ诊断符合率７６．９％（２０／２６）,术前诊断符合率４８．６％（３５／７２）,手术治疗６４例,原发病灶切除率６７．２％（４３／６４）。术后５年生存率为７．８％（５／６４）。本组中腺癌占９６．９％（６２／６４）。结论：ＧＢＣ早期诊断较为困难,应结合临床综合考虑,对ＮｅｖｉｎⅢ～Ⅳ期的ＧＢＣ应以根治术治疗为主,扩大根治术虽能延长某些病人的生存期,但手术并发症多、手术死亡率高,应予关注。     

高温隔离灌注化疗在下肢骨与软组织肉瘤保肢治疗中的价值与限度

为了减低肢体恶性肿瘤治疗中保肢手术的局部复发率，我们从１９９０年开始对５７例下肢ⅡＢ期骨与软组织肉瘤进行术前顺铂或卡铂高温（４１～４３°Ｃ）隔离灌注化疗，同时结合静脉滴注阿霉素。本组进行保肢手术４７例、截肢手术１０例。术前化疗后显示９１％患者局部疼痛完全消失；９５％肿块明显缩小；８９．５％关节活动度改善。术后病理检查肿瘤坏死率９０％～１００％为完全反应者４９例（８６％）；６０％～９０％为部分反应者５例（８．８％）；６０％以下为无反应者３例（５．２％）。术后随访２～５年的２６例保肢者中局部复发２例（７．７％）；术后３年以上随访者２６例，无病存活１６例（６１．５％）。作者认为本法局部效果非常良好，十分利于施行保肢术手，但无助于提高存活率，对截肢者不必应用。     

排钉阻断法贲门周围血管断流术治疗门静脉高压症52例

目的：介绍一种自行设计的简便易行且能有效治疗门静脉高压症的手术方式——“排钉阻断法贲门周围血管断流术”,并进行初步评价。方法：就1998年11月至今所施行的“排钉阻断法贲门周围血管断流术”治疗门静脉高压症52例,对其临床资料进行分析总结。结果：52例均属病毒性肝炎肝硬化,肝功能Child分级为A级9例（17％）,B级31例（62％）,C级12例（21％）。其中急诊手术6例,预防性手术8例,其余均为择期手术。手术过程均顺利,无手术死亡,术后均恢复良好。6例急症手术病人均于术后立即止血,无近期再出血,无肝性脑病发生。随访51例,随访期为术后1个月至术后9年3个月;3例术后出血,再出血率5．77％;4例死亡（术前肝功分级均为Child C级）。其余47例术后6个月复查肝功能,较术前改善者40例（85．1％）,无变化者7例（14．9％）。术后1年内复查食管钡餐检查,35例食管静脉曲张明显好转,11例曲张静脉消失,1例无变化。病人术后劳动能力和生活质量较术前普遍提高。结论：排钉阻断法责门周围血管断流术治疗门静脉高压症简便易行,疗效满意,值得进一步研究及临床推广。     

全麻手术中自体血液回输和异体输血病人T淋巴细胞及其亚群改变的比较

目的 比较自体血液回输及异体输血对病人Ｔ淋巴细胞及其亚群的影响。方法 ６０例脊柱四肢非肿瘤无免疫系统疾病病人随机分为三组,Ⅰ组：自体输血组（ｎ＝２１）,Ⅱ组：异体输血组（ｎ＝２０）,Ⅲ组：不输血组（ｎ＝１９）。三组病人于麻醉前、术后第２ｄ、第７ｄ检测外周静脉血内ＣＤ３＾＋、ＣＤ４＾＋４＾＋／ＣＤ８＾＋比值。结果 三组病人术前各项指标无明显差异（Ｐ〉０．０５）;Ⅰ组和Ⅲ组术后第２ｄ、第７ｄ与术前比较及两组间比较无明显差异（Ｐ〉０．０５）;Ⅱ组病人术后第２ｄ与术前比较及与Ⅰ组、Ⅲ组术后第２ｄ比较ＣＤ３＾＋、ＣＤ４＾＋、ＣＤ８＾＋明显下降（Ｐ〈０．０５）,ＣＤ４＾＋／ＣＤ８＾＋比值无明显改变（Ｐ〉０．０５）,术后第７ｄ各组指标与术前比较及组间比较无明显差异（Ｐ〉０．０５）。结论 自体血液回输对病人Ｔ细胞免疫功能影响较     

食管胃底静脉曲张术后再出血的治疗

目的 探讨食管胃底静脉曲张术后再出血的有效治疗方法。方法 对１９８０年１月－１９９６年１月收治的５８例食管胃底静脉曲张术后再出血的病例的临床资料进行回顾性分析。结果 ７例非手术治疗,５１例手术治疗。手术治疗组中,急诊手术１９例,择期手术３２例。非手术治疗组死亡率为４３％;手术组总死亡率为１７．６％,其中急诊手术死亡率为３６．８％,择期手术死亡率为６．３％。３１例获访０．５－１２年,再出血率２２．６     

Current indication of a modified Sugiura procedure in the management of variceal bleeding

BACKGROUND: The role of gastroesophageal devascularization (Sugiura-rype procedures) for the treatment of variceal bleeding remains controversial. Although Japanese series reported favorable longterm results, the technique has nor been widely accepted in the Western Hemisphere because of a high postoperative morbidity and mortality. The reasons for the different outcomes are unclear. In a multidisciplinary team approach we developed a therapeutic algorithm for patients with recurrent variceal bleeding. STUDY DESIGN: The Sugiura procedure was offered only to patients with well-preserved liver function (Child A or Child B cirrhosis without chronic ascites) who were not candidates for distal splenorenal shunt, transhepatic porto-systemic shunt, or liver transplantation. RESULTS: Fifteen patients with recurrent variceal bleeding underwent a modified Sugiura procedure between September 1994 and September 1997. All but one patient (operative mortality 7%) are alive after a median followup of 4 years. Recurrent variceal bleeding developed in one patient; esophageal strictures, which were successfully treated by endoscopic dilatation, developed in three patients; and one patient experienced mild encephalopathy. Major complications were noted only in patients with impaired liver function (Child B cirrhosis) or when the modified Sugiura was performed in an emergency setting. The presence of cirrhosis or the cause of portal hypertension had no significant impact on the complication rate. CONCLUSIONS: This series was performed during the last decade when all modern therapeutic options for variceal bleeding were available. Our results indicate that the modified Sugiura procedure is an effective rescue therapy in patients who are not candidates for selective shunts, transhepatic porto-systemic shunt, or transplantation. Emergency settings and decreased liver function are associated with an increased morbidity.     

Treatment of choledocholithiasis in patients with liver cirrhosis. Surgical treatment or endoscopic sphincterotomy?

OBJECTIVE: The clinical features of choledocholithiasis were analyzed in cirrhotic patients. The outcomes of surgical treatment and endoscopic sphincterotomy (EST) in this situation were compared and the risk factors predictive of an increased mortality rate were identified. SUMMARY BACKGROUND DATA: In cirrhotic patients, high risk for gallbladder stones in cholecystectomy has been established. Common bile duct stones can often exacerbate liver dysfunction and might be more difficult to treat. METHODS: Among 16 cirrhotic patients with choledocholithiasis, 9 underwent choledocholithotomy and T-tube placement (surgery group) and 7 underwent EST (EST group). Pretreatment clinical data were comparable between groups. RESULTS: Among 16 patients, 15 had biliary tract symptoms and 7 had cholangitis. The surgery group had excessive intraoperative hemorrhage (1576 mL) and a high morbidity rate (66.7%). The mortality rate was 44.4%: 0% in Child A or B classification patients and 80% in Child C patients. The common causes of death were liver failure, postoperative hemorrhage, and sepsis. The EST group had no complications related to procedures, but there was one death (14.3%) due to preexisting liver failure. Hepatic dysfunction, coagulopathy, and cholangitis were factors predictive of an increased mortality rate. CONCLUSIONS: Choledocholithiasis in cirrhotic patients should be treated by EST after liver function and general condition are improved by medical management, except in emergency cases.     

Emergency and elective surgical treatment of portal hypertension. A review of 23 years' experience.

A retrospective review of surgical treatment for portal hypertension during a 23-year period in a regional unit is reported and the immediate and subsequent management of patients with bleeding oesophageal varices is discussed. Fifty-four patients with recurrent varix haemorrhage uncontrolled by conservative methods have been treated by oesophageal transection with a mortality of 22.2% (26.6% for cirrhotic patients). Thirty-two per cent of the cirrhotics were alive after 2 years. Only a minority (12%) of the survivors were considered suitable for a subsequent shunt procedure. Therapeutic portacaval anastomosis has been performed on 65 patients with a 51.2% 5-year survival (43-5% for cirrhotic patients). Further haemorrhage due to shunt thrombosis occurred in 5-3% of cases. The frequent occurrence of portal-systemic encephalopathy, increasing with duration of time following a shunt, is emphasized. The high morbidity and mortality in the poor-risk cirrhotic indicated that this type of patient is unsuitable for a portal-systemic shunt and is better treated by medical means.     

Child C级肝硬化门脉高压症食道胃底静脉破裂出血的治疗

目的 探讨 Ｃｈｉｌｄ Ｃ级肝硬化门脉高压症食道胃底静脉破裂出血病人的安全有效的治疗方案。方法 对 １０９例急性大出血人院的 Ｃｈｉｌｄ Ｃ级肝硬化门脉高压症病人的治疗结果进行回顾性分析,对外科手术（２９例）、内科治疗（６１例）和ＴＩＰＳＳ（１９ 例）三种治疗方法的疗效、并发症和死亡率进行对比。结果 急诊手术、内科治疗、ＴＩＰＳＳ的住院死亡率分别为６５．５％、３６．１％和２６．３％;住院期间再出血率分别为 ２４．ｌ％、３６．ｌ％、１５．８％。随访期的再出血率分别为 ３３．０％、３６．ｌ％和 ２１．４％。住院死亡率手术组显著高于另外两组（Ｐ＜０．０１）。ＴＩＰＳＳ组的住院再出血率及随访期再出血率显著低于内科组（Ｐ＜０．０５和Ｐ＜０．０１）。三组病人的生存率无显著性差异（Ｋａｐｌａｎ－Ｍｅｉｅｒ分析,Ｐ＝０．０７＞０．０５）。结论ＴＩＰＳＳ作为一种微创介入技术是一种挽救 Ｃｈｉｌｄ Ｃ级门脉高压症食管静脉破裂出血病人生命的有效方法。其止血效果不亚于手术治疗,死亡率低于手术治疗,而再出血率低于内科治疗。更长期的疗效尚待进一步研究。     

急诊断流术治疗门脉高压症上消化道大出血的临床体会

目的探讨急诊断流术对肝硬化门脉高压症上消化道大出血的手术治疗效果。方法回顾性分析行急诊手术治疗的59例门静脉高压症食管胃底曲张静脉破裂大出血患者的临床资料,均行脾切除 食管胃底周围血管断流术,其中肝功能Child A级13例,B级34级,C级12例。术前均予三腔二囊管压迫止血,并采用善宁、可利新、立止血等药物治疗。无效者肝功能Child A、B级立即急诊手术,Child C级患者经护肝、抗休克等术前准备后于48 h内急诊手术。结果全组治愈率94.9%。术后2例死亡,术后再出血1例,经保守治疗治愈,此3例均为肝功能Child C级患者。随访42例,平均4.5(1~8)年,3例再发出血,死于肝功能衰竭3例,肝癌2例,余效果良好。结论对于肝硬化门脉高压症上消化道大出血患者,只要适应证掌握适当,果断采取急诊门奇断流手术,是挽救患者生命的重要措施。围手术期处理也很关键。     

贲门周围血管离断并胃底粘膜下血管环扎术治疗门静脉高压症出血的体会

目的 探讨门胸脉高压症并发出血的治疗方法。方法 回顾性分析108例贲门周围血管离断并胃底粘膜下血管环扎术的临床资料。结果 手术总死亡率为7.4%。90例获得随访，随访3年期间死亡9例，再出血率为21％。手术操作较简单，针对性强，适用于基层医院和急诊手术，但急诊手术死亡率高于择期手术。主要死亡原因是肝功能恶化及其并发症。结论 提高疗效的关键是断流要彻底，重视围手术期的处理和熟练掌握技术要领。     

Child-Turcotte-Pugh versus MELD score as a predictor of outcome after elective and emergent surgery in cirrhotic patients

BACKGROUND: Cirrhotic patients who present for elective and emergent surgery pose a formidable challenge for the surgeon because of the high reported morbidity and mortality. The Child-Turcotte-Pugh (CTP) score previously has been used to evaluate preoperative severity of liver dysfunction and to predict postoperative outcome. Recently, a more objective scoring classification, the model for end-stage liver disease (MELD), has been shown to predict accurately the 3-month mortality for cirrhotic patients awaiting transplantation. We sought to compare the CTP and MELD scores in predicting outcomes in cirrhotic patients undergoing surgical procedures requiring general anesthesia. METHODS: During the study period, 40 patients with a history of cirrhosis who required elective (E) or emergent (EM) surgical procedures under general anesthesia were reviewed (E = 24, EM = 16). The preoperative CTP and MELD scores were calculated and patient short- (30-day) and long-term (3-month) outcomes were recorded. RESULTS: There was a significant difference in the 1-month and 3-month mortality rates between the emergent and elective groups (EM group: 1 mo = 19%, 3 mo = 44%; E group: 1 mo = 17%, 3 mo = 21%, P <0.05). There was good correlation between the CP and MELD scores, which was greater in the emergent groups as compared with the elective group (EM: r = 0.81; E: r = 0.65). CONCLUSIONS: Our study shows that cirrhotic patients who undergo surgery under general anesthesia have an extremely high 1- and 3-month mortality rate that progressively increases with severity of preoperative liver dysfunction. Additionally, the MELD score correlates well with the CTP score, providing a more objective predictor of postoperative mortality in cirrhotic patients undergoing surgery.     

Transcatheter aortic valve replacement (TAVR) as bridge therapy restoring eligibility for liver transplantation in cirrhotic patients

Severe aortic stenosis is a widespread valve disease, constituting a contraindication to organ transplantation due to cardiovascular morbidity and projected mortality. Mortality after conventional surgical aortic valve replacement in cirrhotic patients depends upon the Child–Pugh class. In the past few years, transcatheter aortic valve replacement has progressively become the treatment of choice for high‐risk patients with severe aortic stenosis. Here, we report the cases of 3 cirrhotic patients who became eligible for liver transplantation after successful transcatheter aortic valve replacement as bridge therapy.     

食管器械吻合术后上消化道大出血分析及治疗

目的分析胃食管器械吻合术后上消化道大出血的原因及诊疗方法。方法2001年12月~2011年12月间我院行食管癌、贲门癌切除术患者2013例,均采用弯管型吻合器行胸内胃食管吻合术。术后26例患者（出血组）出现上消化道出大出血。对比出血组与未出血组的差异性,分析吻合口出血的影响因素。结果18例患者保守治疗后出血停止,8例患者行二次手术止血。多因素logistic回归分析示吻合方式及术中出血量与术后出血的发生率存在明显的相关性。结论胃食管器械吻合术后上消化道大出血多发生于吻合口、胃残端,吻合方式及术中出血量与术后出血相关,大部分病例经保守治疗出血可停止,保守治疗无效者应积极再次手术止血;术中应采取多种措施减少术后出血几率。     

Surgical shunts and TIPS for variceal decompression in the 1990s

BACKGROUND: In the 1990s, liver transplantations and transjugular intrahepatic portosystemic shunts (TIPS) have become the most common methods to decompress portal hypertension. This center has continued to use surgical shunts for variceal bleeding in good-risk patients who continue to bleed through endoscopic and pharmacologic treatment. This article reports this center's experience with surgical shunts and TIPS shunts from 1992 through 1999. METHODS: Sixty-three patients (Child A, 43 patients; Child B, 20 patients) received surgical shunts: distal splenorenal, 54 patients; splenocaval, 4 patients; coronary caval, 1 patient; and mesocaval, 4 patients. Sixty-two patients had refractory variceal bleeding, and 1 patient had ascites with Budd-Chiari syndrome. Two hundred patients (Child A, 24 patients; Child B, 62 patients; Child C, 114 patients) received TIPS shunts. One hundred forty-nine patients had refractory variceal bleeding, and 51 patients had ascites, hydrothorax, or hepatorenal syndrome. Data were collected by prospective databases, protocol follow-up, and phone contact. RESULTS: The 30-day mortality rate was 0% for surgical shunts and 26% for TIPS shunts; the overall survival rate was 86% (median follow-up, 36 months) for surgical shunts and 53% (median follow-up, 40 months) for TIPS shunts. For surgical shunts, the portal hypertensive rebleeding rate was 6.3%; the overall rebleeding rate was 14.3%. For TIPS shunts, the overall rebleeding rate was 25.5% (30-day, 9.4%; late, 22.4%). There were 4 reinterventions for surgical shunts (6.3%); the reintervention rate for TIPS shunts in the bleeding group was 33%, and the reintervention rate in the ascites group was 9.5%. Encephalopathy was severe in 3.1% of the shunt group and mild in 17.5%; this was not systematically evaluated in the TIPS shunts patients. CONCLUSIONS: Surgical shunts still have a role for patients whose condition was classified as Child A and B with refractory bleeding, who achieve excellent outcomes with low morbidity and mortality rates. TIPS shunts have been used in high-risk patients with significant early and late mortality rates and have been useful in the control of refractory bleeding and as a bridge to transplantation. The comparative role of TIPS shunts versus surgical shunt in patients whose condition was classified as Child A and B is under study in a randomized controlled trial.