Partial embolization as re-treatment of hypersplenism after unsuccessful splenic artery ligation

Ligation of splenic artery(LSA) is used for the treatment of liver cirrhosis with hypersplenism. However, hypersplenism is not significantly improved following LSA treatment in some cases, and there are few reports of retreatment of hypersplenism after LSA. We report the case of a47-year-old man with liver cirrhosis and hypersplenism who underwent LSA treatment, but did not significantly improve. Laboratory tests revealed severe leukocytopeniaand thrombocytopenia. Celiac computed tomography arteriogram and digital subtraction angiography revealed two compensatory arteries connected to the hilar splenic artery from the left gastro-epiploic artery and from the dorsal pancreatic artery. Partial splenic embolization(PSE) was performed through the compensatory arteries. As a result, the patient achieved partial splenic ischemic infarction, and white blood cell and platelet counts rose and remained in the normal range. PSE is an effective therapeutic modality for the retreatment of hypersplenism when other modalities have failed.     

Total splenic artery embolization for splenic artery aneurysms in patients with normal spleen

AIM:To evaluate total embolization of the main splenic artery in patients with splenic artery aneurysms(SAAs)and normal spleen.METHODS:Thirty-five consecutive patients with SAAs were referred for treatment with coil embolization.Patients were classified into two groups:coil embolization of the main splenic artery with complete occlusion of the artery and aneurysms(group A,n=16),and coil embolization of the aneurysmal sac with patency of the splenic artery(group B,n=19).Data on white blood cell(WBC)and platelet counts,liver function,and complications were collected on days 7 and 30,and subsequently at a 6-mo interval postoperatively.Abdominal computed tomography was routinely performed to calculate the splenic volume before and 1 mo after the procedure,and subsequently every 6 mo during follow-up.RESULTS:Coil embolization of the SAAs was technically successful in all 35 patients,with no procedurerelated complications.The post-embolization syndrome,including abdominal pain,fever and vomiting,occurred in six patients(37.5%)in group A and three patients in group B(15.8%).There were no significant differences in WBC and platelet counts between preoperatively and at each follow-up point after the procedures.There were also no significant differences in average WBC and platelet counts between the two groups at each follow-up point.There were significant differences in splenic volume in group A between preoperatively and at each follow-up point,and there were also significant differences in splenic volume between the two groups at each follow-up point.CONCLUSION:Total embolization of the main splenic artery was a safe and feasible procedure for patients with SAAs and normal spleen.     

部分脾栓塞术治疗肝硬化脾功能亢进症

目的探讨部分脾栓塞术(Partial Splenic Embolization,PSE)治疗肝硬化脾功能亢进症的临床疗效及其并发症的防治。方法126例肝硬化并发门脉高压及脾功能亢进症患者,采用Seldinger技术行PSE,用明胶海绵作栓塞剂。术前、后定期复查血常规,测定脾脏长径、厚度及门脉主干及脾静脉内径,观察并发症。结果栓塞面积<30%者8例;30%～60%者66例;60%～80%者42例;>80%者10例。除8例栓塞面积<30%者外,术后患者的外周血细胞均逐步上升,术后1周患者WBC(×109·L-1)、PLT(×109·L-1)、HGB(×g·L-1)分别为7.58±4.52、76.35±28.47、98.36±15.72(P<0.01,vs术前白细胞2.57±0.62、血小板36.63±8.42,P>0.05vs术前血红蛋白96.58±13.46)。术后1月患者的WBC、PLT及HGB分别为4.48±0.86,91.49±38.20及124.46±30.84(P<0.01,vs术前的WBC、PLT及HGB)。术后3～6月超声测定118例脾脏长径、厚度(cm)分别为14.32±3.26,5.68±1.12(P<0.05,vs术前的17.42±2.65,7.54±2.14)。栓塞面积<30%者无并发症,栓塞面积30%～60%者4例(4/66)发生并发症;栓塞面积60%～80%者27例(27/42)发生并发症;栓塞面积大于>80%者均出现并发症(10/10)。并发症包括胸水、腹水、顽固性呃逆、左下肺炎、脾脓肿、脾囊肿、门脉血栓、膈下脓肿等。并发症的发生率及严重程度与脾脏栓塞的面积密切相关(P<0.01)。结论PSE能有效缓解肝硬化患者的脾功能亢进症,掌握合适的栓塞面积可减少并发症的发生率,术前充分准备、术后加强抗炎及对症处理可减少或减轻并发症的发生。     

脾动脉栓塞治疗肝硬化继发脾脏功能亢进的临床效果观察

目的 探讨脾动脉栓塞术（PSE）治疗肝硬化继发脾脏功能亢进的临床效果.方法 选取我院肝硬化继发脾脏功能亢进患者80例,其中研究组48例,行脾动脉栓塞术;对照组32例,行脾脏切除术,比较两组患者的出血量、住院时间、术后恢复、并发症等.结果 与对照组比较,研究组患者的住院时间缩短、出血量减少,差异有统计学意义（P＜0.05）;两组患者术后不良反应比较,差异无统计学意义（P ＞0.05）;PSE后脾局部梗死后门静脉内径减小,与对照组比较差异无统计学意义（P＞0.05）.结论 PSE治疗肝硬化继发脾脏功能亢进临床效果显著,微创易恢复,门静脉宽度变窄,门脉压力降低.     

经皮胃冠状静脉栓塞术联合脾动脉主干截流术治疗肝硬化盗血综合征临床研究*

目的观察经皮胃冠状静脉栓塞术联合脾动脉主干截流术治疗肝硬化盗血综合征患者的疗效。方法在89例肝硬化并发脾功能亢进症伴食管胃底静脉曲张破裂出血患者中,53例接受经皮胃冠状静脉栓塞术联合脾动脉主干截流术治疗,36例行脾动脉主干截流术治疗。在术后1个月、6个月、12个月观察肝功能、血常规等指标变化及再出血和生存情况。结果术后1个月、6个月、12个月联合组再出血率分别为0.0%、5.7%和15.1%,而脾动脉主干截流术治疗患者分别为0.0%、16.7%（P<0.05）和44.4%（P<0.05）;术后两组白细胞和血小板计数均升高,但在6个月后又有所下降,两组生存患者 Child-Pugh评分无显著相差（P>0.05）。结论采用经皮胃冠状静脉栓塞术联合脾动脉主干截流术治疗肝硬化并发食管胃底静脉曲张破裂出血患者损伤小、安全性好,控制再出血作用肯定。     

183例部分脾动脉栓塞的护理体会

目的探讨部分脾动脉栓塞术治疗肝硬化脾功能亢进的护理方法。方法对183例肝硬化所致脾功能亢进患者采用Seldinger技术行部分性脾动脉栓塞,术前及术后给予精心护理。结果术后所有患者白细胞、血小板计数逐渐提升至正常水平,脾区疼痛的发生率为97．81％,发热发生率为86．34％,腹水发生率为15．85％,均于术后2周内恢复正常,且未出现脾脓肿等严重并发症。结论部分脾动脉栓塞术治疗肝硬化脾功能亢进疗效理想,方法安全。术前做好详细的病情评估及严格掌握适应证,术后重视病情观察和护理可减少并发症的发生。     

Comparison of total splenic artery embolization and partial splenic embolization for hypersplenism

AIM: To evaluate whether total splenic artery embolization (TSAE) for patients with hypersplenism delivers better long-term outcomes than partial splenic embolization (PSE).METHODS: Sixty-one patients with hypersplenism eligible for TSAE (n = 27, group A) or PSE (n = 34, group B) were enrolled into the trial, which included clinical and computed tomography follow-up. Data on technical success, length of hospital stay, white blood cell (WBC) and platelet (PLT) counts, splenic volume and complications were collected at 2 wk, 6 mo, and 1, 2, 3, 4 years postoperatively.RESULTS: Both TSAE and PSE were technically successful in all patients. Complications were significantly fewer (P = 0.001), and hospital stay significantly shorter (P = 0.007), in group A than in group B. Post-procedure WBC and PLT counts in group A were significantly higher than those in group B from 6 mo to 4 years (P = 0.001), and post-procedure residual splenic volume in group A was significantly less than that observed in group B at 1, 2, 3 and 4 years post-procedure (P = 0.001). No significant differences were observed in red blood cell counts and liver function parameters between the two groups following the procedure.CONCLUSION: Our results indicate that TSAE for patients with hypersplenism not only delivers a better long-term outcome, but is also associated with lower complication rates and a shorter hospital stay than PSE.     

微导管和聚乙烯醇在部分脾栓塞中的应用

目的:评价超选择插管和聚乙烯醇颗粒技术在部分脾栓塞临床应用中的价值.方法:肝硬化合并门静脉高压伴脾功能亢进患者80例,采用超选择插管至脾动脉分支,行部分脾栓塞.每例患者共接受1-3次栓塞.栓塞材料是聚乙烯醇(polyvinylalcohol,PVA)微粒,直径300-500μm.收集每次栓塞前、后资料,包括症状、体征、外周血象、CT、上消化道内镜所见等,经统计学处理后进行分析.结果:共进行105次部分脾栓塞,其中15例作了第二次栓塞,5例作第三次栓塞.栓塞范围40%-70%,并且有83次栓塞后出现发热,持续3-30d.83次出现腹痛,其中26次需用强效止痛药.5例少量胸腔积液,经保守治疗后吸收.未出现脾脓肿等并发症.术后24h外周血白细胞、血小板计数开始升高(P<0.05).栓塞后3mo内,78例白细胞维持在正常水平,79例BPC维持在正常范围.栓塞后食欲、体能改善,胃底食管静脉曲张程度减轻,随访期间未发现上消化道大出血者.结论:部分脾栓塞治疗脾功能亢进,能减轻门静脉高压,降低上消化道大出血发生率,有效改善血象,提高机体免疫力和生活质量.     

失代偿期乙型肝炎肝硬化患者行脾切除术与脾动脉部分栓塞术治疗疗效观察

目的观察失代偿期乙型肝炎肝硬化患者行脾切除术或脾动脉部分栓塞术的疗效。方法选择我院2010年2月~2013年2月收治的采用脾切除术治疗的失代偿期乙型肝炎肝硬化患者50例和采用脾动脉部分栓塞术治疗的失代偿期乙型肝炎肝硬化患者28例。另选择我院同期收治入院的采用常规保守治疗的患者30例作为对照组。结果随访3组患者治疗后1年,对照组外周血白细胞和血小板计数分别为（3.3±0.6）×10⁹/L和（56.3±5.8）×10⁹/L,显著低于脾切除组（6.2±0.6）×10⁹/L和（126.5±12.7）×10⁹/L（P<0.05）,或脾动脉栓塞组（7.2±0.8）×10⁹/L和（112.8±10.6）×10⁹/L（P<0.05）;对照组CD₄、CD₄/CD₈比值和白蛋白分别为（32.5±3.5） %、（1.1±0.2）和（24.9±3.8） g/L,显著低于脾切除组（41.8±4.2）%、（1.9±0.2）和（29.1±3.7） g/L（P<0.05）,或脾动脉栓塞组（41.6±4.9）%、（1.7±0.2）和（28.2±4.0） g/L（P<0.05）,而CD₈、TBIL、ALT、PT分别为（32.3±4.7） %、（42.7±21.5） μmol/L、（67±35） IU/L、（24.8±3.4） s,显著高于脾切除组（22.7±3.4）%、（29.2±12.4） μmol/L、（40±26） IU/L、（16.2±3.4）s（P<0.05）,或脾动脉栓塞组（23.0±3.6） %、（35.2±13.4） μmol/L、（56±20） IU/L、（16.5±2.9）s（P<0.05）;对照组膈下感染、肺部感染、肺不张、脾静脉炎、上消化道出血发生率分别为43.3%、56.7%、26.7%、20.0%、23.3%,显著高于脾切除组的12.0%、14.0%、6.0%、4.0%、8.0%（P<0.05）,或脾动脉栓塞组的10.7%、14.3%、3.6%、3.6%、7.1%（P<0.05）。结论脾切除术或脾动脉部分栓塞术后,患者肝功能稳定,不同程度地减少了感染和上消化道出血的发生率。     

脾动脉栓塞术对肝癌伴脾亢患者免疫功能的影响

目的:研究脾切除及部分脾动脉栓塞术(PSE)对肝癌伴脾亢患者免疫功能的影响.方法:前瞻性研究肝癌合并脾亢的患者69例,全部经过影像学及实验室检查证实为肝癌合并脾亢,随机分为两组,其中PSE组37例,脾切除组32例.PSE组实施肝癌介入治疗同时行PSE(双介入)治疗,脾切除组实施肝癌介入治疗同时行外科切脾.观察两组术前术后的外周血象、免疫系统指标及临床症状体征的变化.结果:在PSE组.术后测WBC、PLT,与术前比较均有显著性差异(P<0.05);术后测RBC与术前相比无显著差异(P>0.05).在脾切除组,术后测WBC、PLT,与术前比较均有显著性差异(P<0.05);术后测RBC与术前相比无显著差异(P>0.05).术前测PSE组与脾切除组的CD4+、CD4+/CD8+,两组问无显著差异,术后7 d、术后28 d测CD4+,两组间有显著差异(t=16.063,9.409、P<0.05).术后7 d、术后28 d测CD4+/CD8+,两组间有显著差异(t=2.060,2.228,P<0.05).在PSE组,术后测CD4+、CD4+/CD8+分别与术前比较,均有显著性差异(P<0.05).在脾切除组,术后测CD4+、CD4+/CD8+分别与术前比较,均无显著性差异(P>0.05).两组病例术后并发症(发热、腹痛、腹水、胸腔积液)发生率的比较均无显著性差异(P>0.05).结论:PSE与传统脾切除术相比,有操作简单、并发症少、术后细胞免疫功能改善等优点,取得了更好的临床治疗效果.     

肝动脉及部分脾动脉栓塞治疗肝癌伴脾功能亢进

目的 观察采用肝动脉栓塞化疗联合部分脾动脉栓塞治疗原发性肝癌合并脾功能亢进的疗效。方法 原发性肝癌伴肝硬化脾功能亢进患者３４例,采用经皮穿刺肝动脉插管化疗栓塞及脾动脉部分栓塞治疗,治疗前后测肝功,免疫指标,外周血及Ｂ超,ＣＴ等。结果 术后ＣＴ随访显示肝脏瘤体缩小２４例,占７０．５８％,其中缩小５０％以上占１３例,２例治疗后行二期手术切除;脾脏栓塞后ＣＴ复查缩小最大３４．７％,最小２０．６％,治疗后     

Value of portal hemodynamics and hypersplenism in cirrhosis staging

AIM: To determine the correlation between portal hemodynamics and spleen function among different grades of cirrhosis and verify its significance in cirrhosis staging. METHODS: The portal and splenic vein hemodynamics and spleen size were investigated by ultrasonography in consecutive 38 cirrhotic patients with cirrhosis (Child's grades A to C) and 20 normal controls. The differences were compared in portal vein diameter and flow velocity between patients with and without ascites and between patients with mild and severe esophageal varices. The correlation between peripheral blood cell counts and Child's grades was also determined. RESULTS: The portal flow velocity and volume were significantly lower in patients with Child's C (12.25±1.67 cm/s vs 788.59±234 mm/min, respectively) cirrhosis compared to controls (19.55±3.28 cm/s vs 1254.03±410 mm/min, respectively) and those with Child's A (18.5±3.02 cm/s vs 1358.48±384 mm/min, respectively) and Child's B (16.0±3.89 cm/s vs 1142.23±390 mm/min, respectively) cirrhosis. Patients with ascites had much lower portal flow velocity and volume (13.0±1.72 cm/s vs1078±533 mm/min) than those without ascites (18.6±2.60 cm/s vs1394±354 mm/min). There was no statistical difference between patients with mild and severe esophageal varices. The portal vein diameter was not significantly different among the above groups. There were significant differences in splenic vein diameter, flow velocity and white blood cell count, but not in spleen size, red blood cell and platelet counts among the various grades of cirrhosis. The spleen size was negatively correlated with red blood cell and platelet counts (r= -0.620 and r= -0.8.34, respectively). CONCLUSION: An optimal system that includes parameters representing the portal hemodynamics and spleen function should be proposed for cirrhosis staging.     

Splenic arteriovenous fistula and sudden onset of portal hypertension as complications of a ruptured splenic artery aneurysm： Successful treatment with transcatheter arterial embolization. A case study and review of the literature

Splenic arteriovenous fistula (SAVF) accounts for an unusual but well-documented treatable cause of portal hypertension. A case of a 50-year-old multiparous female who developed suddenly portal hypertension due to SAVF formation is presented. The patient suffered from repeated episodes of haematemesis and melaena during the past twelve days and thus was emergently admitted to hospital for management. Clinical and laboratory investigations established the diagnosis of portal hypertension in the absence of liver parenchymal disease. Endoscopy revealed multiple esophageal bleeding varices. Abdominal computed tomography (CT) and transfemoral celiac arteriography documented the presence of a tortuous and aneurysmatic splenic artery and premature filling of an enlarged splenic vein, findings highly suggestive of an SAVF. The aforementioned vascular abnormality was successfully treated with percutaneous transcatheter embolization. Neither recurrence nor other complications were observed.     

部分脾栓塞对肝硬化门静脉高压血流动力学影响(附24例临床观察)

探讨部分脾栓塞术 (PSE)对肝硬化门静脉高压血流动力学的影响。 2 4例肝硬化门静脉高压患者采用PSE治疗 ,应用彩色多普勒超声仪观察门静脉高压血流动力学指标的变化并观察门静脉高压主要相关症状变化。PSE后门静脉高压血流动力学指标均降低 ,与术前比较 ,差异有显著性意义 (P <0 0 0 1) ,术后 4W与 2W比较差异无显著性 (P >0 0 5 )。PSE后与门静脉高压相关的主要症状得到改善。PSE对肝硬化门静脉高压血流动力学有重要影响 ,术后可显著降低门静脉压力 ,此对相应症状的改善有重要意义     

脾切除术与部分脾动脉栓塞术治疗肝硬化脾功能亢进近期疗效比较的Meta分析

目的系统评价部分脾动脉栓塞术(PSE)和脾切除术治疗肝硬化脾功能亢进的疗效。方法计算机检索2005年1月1日-2015年5月30日Medline、Embase、Web of Science、中国知网、万方数据库、维普收录的评估PSE与脾切除术治疗肝硬化脾功能亢进疗效的文献,文献纳入由两位研究者独立筛选,经过质量评价与数据提取后,采用Rev Man5.3进行Meta分析。结果最终纳入10篇对照研究,共638例患者。4项研究的合并分析结果显示术后1周PSE组对外周血小板的影响明显低于脾切除术组[加权均数差(WMD)=-65.71,95%可信区间(95%CI):-120.24~-11.18,P=0.02];而术后1个月两组差异无统计学意义(WMD=0.68,95%CI:-8.16~9.52,P=0.88);2项研究的合并分析结果显示术后1个月PSE组自然杀伤细胞的含量较脾切除术组高(WMD=6.03,95%CI:3.80~8.26,P0.001),且术后1年两组差异仍有统计学意义(WMD=3.60,95%CI:1.25~5.96,P=0.003);3项研究合并分析结果显示PSE组较脾切除术组住院治疗时间明显缩短(WMD=-2.52,95%CI:-3.36~-1.67,P0.001)。结论 PSE组术后血小板前期升高较脾切除术组缓和,而远期并无明显区别;PSE组在对术后维持患者持免疫系统的储备功能、缩短住院时间、减少并发症等方面有明显优势。     

部分脾动脉栓塞术后短期疗效观察

通过对肝炎肝硬化门静脉高压患者行部分脾动脉栓塞术（PSE）治疗,观察短期术后肝功能、血细胞计数和并发症发生情况。方法63例肝炎肝硬化患者术前行B超或（和）CT检查,常规行PSE。结果在术前,患者血清ALT、ALB和TBIL分别为（49.9±9.8） U/L、（35.6±1.6） g/L和（22.47±3.7）μmol/L,而术后8 d则分别为（24.4±3.1） U/L、（33.7±1.7） g/L和（30.2±4.4）μmol/L,均变化显著（P〈0.05）;术前WBC、RBC和PLT分别为（2.36±1.24）×10^9/L、（3.62±0.51）×10^12/L和（45.3±20.2）×10^9/L,术后8 d则分别为（6.32±2.16）×10^9/L、（3.66±0.47）×10^12/L和（154.2±161.2）×10^9/L,白细胞和血小板升高显著（P〈0.05）;所有患者在术后均出现不同程度的发热、脾区疼痛。结论 PSE虽可减轻肝硬化脾功能亢进症患者血细胞减少,但术后短期内黄疸加深,须要加强保肝和退黄治疗。     

肝硬化脾功能亢进合并感染性心内膜炎一例

<正>1病例资料患者男性,45岁。因呼吸困难、发热2个月余于2011年3月14日入院。患者2个月前劳累后开始出现呼吸困难,并逐渐加重,伴有全身乏力,头晕,黑矇,两次行走中出现晕厥,休息后症状可缓解。体温间断升高,波动于37.0℃～38.5℃,无寒战、盗汗、胸痛、咳嗽、咳痰,无皮疹、红斑、肌肉     

腹腔镜脾脏切除术治疗肝硬化脾功能亢进症疗效分析

目的 探讨腹腔镜脾脏切除术治疗肝硬化脾功能亢进症患者的疗效。方法 在60例肝硬化脾功能亢进症患者,按住院号尾数单双号分为两组, 29例接受腹腔镜脾脏切除术治疗, 31例接受开腹脾脏切除术治疗,随访3个月。结果 腹腔镜组术中出血量为（332.34±36.26） ml,显著少于开腹组【（452.27±49.84） ml,P<0.05】,住院时间和拔管时间为（6.52±2.68） d和（5.23±1.71） d,显著短于开腹组【（9.58±3.06） d和（8.04±2.24） d,P<0.05】,但平均所需手术时间为（168.36±21.31） min,显著长于开腹组【（104.17±31.24） min,P<0.05】;手术前后两组肝功能指标和血细胞计数变化无统计学差异（P>0.05）;随访3个月,两组主要并发症,如胸腹腔积液和肺部感染发生率相比,差异无统计学意义（P>0.05）。结论 腹腔镜脾脏切除术对肝硬化脾功能亢进症具有较好的治疗效果,尽管所需手术时间有所延长,但术后康复较快。     

Effectiveness of partial splenic embolization as treatment for hypersplenism in thalassaemia major: a 7-year follow up.

Partial splenic embolization is an alternative procedure to total splenectomy in patients with hypersplenism, and was performed in 10 patients with beta-thalassaemia major who were then followed for 5 to 7 years. The results were compared with those of a 7-yr follow-up of 6 splenectomized thalassaemics. The blood consumption decreased and the leucocyte counts increased in both groups of patients. However, after partial splenic embolization, severe thrombocytosis--which is typical of splenectomized patients--did not develop and there were no severe complications from the operation, such as infections or reappearance of hypersplenism. In addition, the minor surgical injury and avoidance of abdominal scars were further advantages of partial splenic embolization over total splenectomy.     

Evaluation of the effect of partial splenic embolization on platelet values for liver cirrhosis patients with thrombocytopenia

AIM： TO investigate the effect of partial splenic embolization （PSE） on platelet values in liver cirrhosis patients with thrombocytopenia and to determine the effective embolization area for platelet values improvement.
METHODS： Blood parameters and liver function indicators were measured on 10 liver cirrhosis patients （6 in Child-Pugh grade A and 4 in grade B） with thrombocytopenia （platelet values 〈 80 × 10^3/μL） before embolization. Computed tomography scan was also needed in advance to acquire the splenic baseline. After 2 to 3 d, angiography and splenic embolization were performed. A second computed tomography scan was made to confirm the embolization area after 2 to 3 wk of embolization. The blood parameters of patients were also examined biweekly during the 1 year follow-up period. RESULTS： According to the computed tomography images after partial splenic embolization, we divided all paUents into two groups： low （〈 30%）, and high （≥ 30%） embolization area groups. The platelet values were increased by 3 times compared to baseline levels after 2 wk of embolization in high embolization area group. In addition, there were significant differences in platelet values between low and high embolization area groups. GPT values decreased significantly in all patients after 2 wk of embolization. The improvement in platelet and GPT values still persisted until 1 year after PSE. In addition, 3 of 4 （75%） Child-Pugh grade B patients progressed to grade A after 2 mo of PSE. The complication rate in 〈 30% and ≥30% embolization area groups was 50% and 100%, respectively. CONCLUSION： Partial splenic embolization is an effective method to improve platelet values and GPT values in liver cirrhosis patients with thrombocytopenia and the ≥ 30% embolization area is meaningful for platelet values improvement. The relationship between the complication rate and embolization area needs further studies.