脾肾分流联合断流术治疗门静脉高压症的效果及对血流动力学的影响

目的:探讨脾切除脾肾静脉分流加断流术(联合术)和单纯断流术的临床疗效及对门静脉血流动力学的影响.方法:对联合组11例、断流组18例运用彩色多普勒超声(DCFI)、间接门静脉造影(IPVG)、磁共振门脉血管成像(MRPVG)以及术中自由门静脉压(FPP)的测定,观察两种手术对门静脉系统血流动力学的影响及近期疗效.结果:MRPVG测得的PV和SV的血流量与DCFI测得的结果间差异无显著性.MRPVG对门静脉系统的成像效果好.断流组PV流量减少(417.48±239.37)ml/min,联合组减少(457.30±227.43)ml/min,两者间无显著差异.断流组FPP降低(3.83±1.73)mmHg,联合组降低(5.49±4.51)mmHg,联合组降压效果明显优于断流组.结论:MRPVG应作为PHT首选检查手段.联合术切断了门奇间反常的血流侧支,在降低FPP的同时又能保持一定的肝脏门静脉血流灌注,临床疗效满意,有望成为门静脉高压症的首选术式.     

肝癌切除联合脾动脉结扎治疗肝癌并门静脉高压症

目的 探讨肝癌切除联合脾动脉结扎治疗肝癌并门静脉高压症的外科策略和疗效.方法 回顾性分析2007年9月至2011年12月我院收治的肝癌合并门静脉高压症患者31例的临床资料和手术疗效.结果 患者术前血小板计数平均为(59.50±22.43)×109/L,术后第2周血小板计数为(136.01±70.41)×109/L(P<0.05).术前白细胞计数平均为(3.32±1.25)×109/L,术后第2周白细胞计数为(9.63±3.36)× 109/L(P<0.05).术前、术后红细胞计数以及脾动脉结扎前后门静脉压力相比较无统计学意义.结论 选择性使用肝癌切除联合脾动脉结扎治疗肝癌并门静脉高压症可以缓解脾亢情况,有益于康复.     

联合断流和分流术治疗门静脉高压症(附180例分析)

目的 探讨联合断流和分流术治疗门静脉高压症的临床效果.方法 对1990年5月至2010年5月采用联合断流和分流手术治疗180例门静脉高压症的临床资料进行回顾性分析.结果 术前自由门静脉压力(FPP)平均为34 cm H2O;脾切除、脾腔或肠腔分流术后FPP下降10 cmH2O;手术后FPP平均为24.5 cm H2O....     

不阻断肝门切除肝癌的近期临床观察

目的: 探讨不阻断入肝血流肝切除手术的安全性及技巧,以及对残肝功能和术后并发症的影响.方法: 利用病例对照研究,比较阻断与不阻断入肝血流切除肝癌,观察术后并发症发生率、术中出血量等指标.结果: 甲组(阻断入肝血流,n=59),乙组(不阻断入肝血流,n=42).甲组和乙组术中估计失血量分别为:(892±843)ml,(914±894)ml,P>0.05.甲组和乙组术中输血量分别为:(955±992)ml,(1220±982)ml,P>0.05.甲组和乙组术后ALT恢复正常时间分别为:(17±6)d,(12±4)d,P<0.05.甲组和乙组术后Tbil恢复正常时间分别为:(18±7)d,(13±5)d,P<0.05.甲组和乙组术后并发症发生率分别为:41.2%,12.5%,P<0.05.结论: 本组资料显示不阻断入肝血流切肝可有效防止肝脏缺血再灌注损伤和降低术后并发症发生率,应用不阻断入肝血流切肝可行、安全.     

原位二级脾蒂离断脾切除术的临床应用

目的 探讨原位二级脾蒂离断脾切除术在择期脾切除中的临床应用.方法 比较分析2000年6月至2008年5月问106例原位二级脾蒂离断脾切除术与118例传统睥切除术的手术时间、术中出血、术后住院时间以及术后并发症等临床资料.结果 与传统组比较,原位组的术中出血量、术后住院时间显著缩短[(310.4±55.2)ml vs(554.3±71.6)ml;(12.9±4.3)vs(15.7d±6.8)d,P<0.05)];门静脉血栓和胰漏的发生率显著降低[(0.9%vs 6.7%;O vs 7.6%,P<0.05)];手术时间虽有延长,但两组相比差异无统计学意义(P>0.05).结论 在择期病理脾切除时,原位二级脾蒂离断脾切除术是一种较好的备选术式方案.     

联合术治疗门静脉高压症22例

为观察断流加分流联合术治疗门静脉高压症的效果 ,总结采用联合断流加脾肾静脉分流术(即联合术 )治疗 2 2例门静脉高压症的经验。均行择期手术 ,无手术死亡。术后随访 18例 ,再出血 1例 ,肝性脑病 1例。术前自由门静脉压 (FPP)为 ( 3.96± 0 .39)kPa ,脾肾分流术后FPP为 ( 2 .2 8± 0 .35)kPa ,断流术后FPP为 ( 2 .71± 0 .38)kPa。断流加分流术既保留了断流术的优点 ,又降低了门静脉压力 ,同时还有利于门静脉向肝的血流灌注     

选择性断流术对门静脉系统血栓形成的影响

目的 探讨选择性断流术对肝硬化门静脉高压症患者术后门静脉系统血栓(portal vein thrombosis,PVT)发生率及血栓发生严重程度的影响.方法 收集我院普外科28例因门静脉高压症行选择性断流术的临床资料,比较术前1周、术后2周、术后2个月及术后6个月血栓发生情况.结果 (1)门静脉高压症患者门静脉系统血栓形成手术前后均与门静脉血流速度呈负相关,术前与血小板数目呈负相关,但术后无明显相关性.(2)选择J生断流术术后门静脉系统血栓发生率较高,且术后6个月内Ⅱ级以上血栓发生率有所上升.结论 选择性断流术患者术后较长时间内,尤其是术后6个月内,应积极随访门静脉系统血栓情况.     

应用术中FPP监测选择肝硬化门静脉高压症断分流术式的研究

目的 探讨肝硬化门静脉高压症(PHT)最佳的手术方式.方法 对36例PHT患者依据断流术后门静脉压力(FPP)的变化,选择FPP＜32cm H2O的患者22例只施行断流术(断流组),FPP≥32cm H2O的患者14例加行近端脾肾分流联合术(断分流组),并结合术前、术后门静脉血流动力学、断流及断分流后FPP变化及术后随访等,评价两组不同手术对门静脉血流动力学的影响及近、远期效果.结果 断流组断流前后FPP分别为(38.01±1.57)cm H2O和(27.41±1.90)cm H2O,手术前后差异有统计学意义;断分流组断流前后FPP分别为(37.68±1.98)cm H2O和(35.11±2.67)cm H2O,差异无统计学意义,联合分流后FPP降低为(22.86±3.74)cm H2O,差异有统计学意义.随访再出血率:断流组10.53%,断分流组8.33%.结论 根据手术前、后门静脉血流动力学状况和断流术前后的FPP的变化,可以选择最佳的手术方式;如果断流术后FPP下降不明显,或FPP仍≥32cm H2O,则加做分流手术,通过术中FPP监测选择正确的术式可以达到最佳的临床效果.     

三种不同术式对门静脉血流动力学的观测

目的 :测定分流 (SRS)加断流手术 (PCDV)前后门静脉系统血流动力学变化 ,评价其在门静脉高压症外科治疗中的价值。方法 :应用彩色多普勒检测 99例门静脉高压症病人手术前后对门静脉系统的血流动力学的影响 ,术中动态测量门静脉压力。结果 :①SRS +PCDV组 :术后PVF减少 36 .1 0 %± 7.8% ,FPP下降 33 .99%± 9.53 %。FPP的下降与PVF的减少呈正相关 ,PVF和FPP较术前下降 (P <0 .0 5) ,但维持在正常高限且保持门静脉向肝血流 ;②SRS +PCDV组术后的PVF和FPP均介于断流组与脾肾分流组之间 ,且各组之间有显著差异 (P <0 .0 5)。结论 :分流手术后门静脉血流向肝内高灌注 ,门静脉系统瘀血状态依然存在。分流术后门静脉高压瘀血状态缓解 ;门静脉血流肝内灌注显著减少。分流术后门静脉压力降低 ,加做断流术后门静脉压力有不同程度回升 ,术后的PVF和FPP均介于断流术和分流术之间 ,该术式明显优于单纯分流术或断流术。     

门体静脉分流术的术式选择

以血流动力学的变化为主要依据选择合理的术式是提高肝硬化门静脉高压症手术效果的关键.门静脉已成为流出道或门静脉入肝血量大量减少者,可行全门体静脉分流术;门静脉入肝血流量中等量减少,则几乎可施行各种分流手术和断流手术;门静脉入肝血流少量减少者可用脾切除断流术治疗.脾切除断流术后自由门静脉压力(FPP)值可以作为选择手术方式的依据.脾动脉结扎后FPP的变化最大.根据FPP下降的绝对值和幅度基本上能判断是行断流术或分流术,如下降不明显,表明肝内阻力高.需行分流或分流加断流术;如下降明显,FPP<22mmHg(1mmHg=0.133kPa)时,可行断流术.脾肾静脉分流加断流的联合手术有诸多优点.应作为治疗肝硬化PHT的首选术式.     

Massive ascites after living donor liver transplantation with a right lobe graft larger than 0.8% of the recipient’s body weight

Shirouzu Y, Ohya Y, Suda H, Asonuma K, Inomata Y. Massive ascites after living donor liver transplantation with a right lobe graft larger than 0.8% of the recipient’s body weight.
Clin Transplant 2010: 24: 520–527.
© 2009 John Wiley & Sons A/S. Abstract: Background: There are only limited data on post‐transplant ascites unrelated to small‐sized grafts in living donor liver transplantation (LDLT). Methods: The subjects were 59 adult patients who had received right lobe LDLT with a graft weight‐to‐recipient weight ratio (GRWR) > 0.8%. Patients were divided into either Group 1 (n = 14, massive ascites, defined as the production of ascitic fluid > 1000 mL/d that lasted longer than 14 d after LDLT) or Group 2 (n = 45, no development of massive ascites). Patients were followed for a median period of 3.0 yr (range, 0.5–7.5 yr). Results: Group 1 had both higher Model for End‐Stage Liver Disease score and Child‐Pugh score than Group 2. Portal venous flow volume just after reperfusion was significantly greater in Group 1 than Group 2 (307.8 ± 268.8 vs. 176.2 ± 75.0 mL/min/100 g graft weight, respectively; p < 0.05). Post‐transplant infectious complications including ascites infection developed more frequently within the first post‐transplant month in Group 1. Massive ascites was significantly associated with early graft loss (p < 0.05). Conclusion: Post‐transplant massive ascites associated with portal over‐perfusion into the graft liver can develop in patients with a GRWR over 0.8%. Recipients with post‐transplant massive ascites require careful management to prevent infection.     

Arthroscopic approach to the posterior compartment of the knee using a posterior transseptal portal

Arthroscopic surgery of the posterior compartment of the knee is difficult when only two anterior portals are used for access because of the inaccessibility of the back of the knee. Since its introduction, the posterior transseptal portal has been widely employed to access lesions in the posterior compartment. However, special care should be taken to avoid neurovascular injuries around the posteromedial, posterolateral, and transseptal portals. Most importantly, popliteal vessel injury should be avoided when creating and using the transseptal portal during surgery. Purpose of the present study is to describe how to avoid the neurovascular injuries during establishing the posterior three portals and to introduce our safer technique to create the transseptal portal. To date, we have performed arthroscopic surgeries via the transseptal portal in the posterior compartments of 161 knees and have not encountered nerve or vascular injury. In our procedure, the posterior septum is perforated with a 1.5-3.0-mm Kirschner wire that is protected by a sheath inserted from the posterolateral portal and monitored from the posteromedial portal to avoid popliteal vessel injury.     

Extrahepatic portal hypertension treated by anastomosing inferior mesenteric vein to left portal vein at Rex recessus

For the treatment of recurrent bleeding despite sclerotherapy or clinically significant hypersplenism, portosystemic shunt procedures should be performed in cases of extrahepatic portal hypertension caused by extrahepatic portal vein thrombosis. A novel alternative to portosystemic shunt procedures in extrahepatic portal hypertension is mesenterico-left portal bypass. Portal vein thrombosis is bypassed by an autologous vein graft (usually left internal jugular vein) interposed between superior mesenteric vein and left portal vein. In the presence of an enlarged right gastroepiploic vein, the distal end of this vein can be anastomosed to left portal vein without disturbing its proximal end. Herein, the authors report a case of extrahepatic portal hypertension treated by anastomosing enlarged inferior mesenteric vein to left portal vein to bypass portal vein thrombosis.     

Flow- and pressure-adapted portal arterialization in dogs

The effects of portal arterialization after portacaval shunt were studied in dogs. Flow- and pressure-adapted portal arterialization was performed by mounting a Teflon cuff on an autogenous vein bypass graft between the hepatic stump of the portal vein and the right renal artery. Immediately following operation, the total hepatic blood flow and intrahepatic portal venous pressure were within normal range. Eight weeks after operation, the intrahepatic portal venous pressure remained within the preoperative range, while total hepatic blood flow had increased double or triple. However, structual change due to increased flow was absent in the liver, even sixteen months after operation. Body weight, liver enzyme chemistry, ICG clearance rate, and amino acid metabolism were well maintained for the entire period of investigation. These findings suggest that sequelae such as hepatic encephalopathy and impaired hepatic metabolism after portacaval shunt can be avoided by portal arterialization, in the presence of an appropriate flow and pressure.     

Radical esophagogastrectomy for unshuntable extrahepatic portal hypertension with bleeding varices: Report of a case

A 29-year-old woman with idiopathic portal hypertension was referred to our department for the surgical management of repetitive bleeding from esophageal and gastric varices. At the age of 16 years she had undergone a splenectomy with esophageal transection followed by endoscopic sclerotherapy which had been performed a total of 24 times. Although vericeal hemorrhage was prevented for several months, bleeding from gastric varices and portal hypertensive gastropathy was not able to be controlled readily by endoscopic sclerotherapy from when she was 26 years old. On admission, angiographic studies showed a complete obstruction of the portal vein; however, a portosystemic shunt operation was not able to be performed due to her previous splenectomy. To control her repetitive bleeding, we decided to perform a total gastrectomy and distal esophagectomy with reconstruction by a Roux-en-Y esophagojejunostomy. Her postoperative course was uneventful, and no episodes of recurrent bleeding or other complications have developed, indicating that her quality of life has dramatically improved. Thus, we conclude that distal esophagectomy and total gastrectomy constitute an effective surgical treatment for unshuntable extrahepatic portal hypertension.     

肝硬化脾切除术后门静脉系统血栓形成的原因分析

目的 探讨肝硬化门静脉高压患者行脾脏切除+贲门周围血管离断术后门静脉系统血栓(portal vein thrombosis,PVT)形成的原因.方法 回顾性分析我院2004年1月至2010年1月204例肝炎后肝硬化门静脉高压症行手术治疗患者的临床资料.结果 其中150例行脾切除+贲门周围血管离断术,54例行脾脏部分切除术+贲门周围血管离断术.术后发生PVT30例,未发生PVT174例;发生PVT患者的门静脉和脾静脉直径、术后门静脉血液流速及术后并发症与未发生PVT患者有显著性差异(P<0.05),脾脏部分切除术后患者PVT的发生率明显比脾脏切除患者低,有显著性差异(P<0.05).结论 门静脉和脾静脉直径、门静脉血液流速及术后并发症是肝硬化门脉高压症脾切+贲门周围血管离断术后PVT形成的危险因素,脾脏部分切除术可有效减少断流术后PVT的发生.     

Mesorenal shunt using inferior mesenteric vein and left renal vein in a case of LDLT

Adult-to-adult living donor liver transplantation (LDLT) has become an established treatment option around the world. However, small-for-size graft syndrome remains one of the most serious complications affecting transplant outcomes. Excessive portal hypertension and overperfusion have been shown to play a causative role in this graft injury. Recently, portal hypertension per se has been considered detrimental to graft function, and thus to be avoided for successful outcomes after LDLT. We constructed a mesorenal shunt with anastomosis of the inferior mesenteric vein and left renal vein in the case of an LDLT recipient who showed high portal vein pressure after graft reperfusion. The inferior mesenteric vein is close to the left renal vein, and the anastomosis was obtained with relative ease. The shunt was effective in decreasing portal vein pressure, and postoperative graft function was satisfactory. This new method represents an option for attenuating portal hypertension when elevated portal vein pressure is observed in adult LDLT after graft reperfusion.