门静脉系统抗凝预防断流术后门静脉系血栓形成

目的 探讨门静脉高压症断流术后门静脉系血栓形成的预防方法。方法 将７１例肝硬化门静脉高压症患者分为２组：Ａ组３６例在断流术中经脾静脉分支插入抗凝管,术后行门静脉系统凝治疗;Ｂ组３５例断流术后未行门静脉系抗凝治疗。结果 术后３个月内彩超检查,Ａ组门静脉系均未见血栓形成,Ｂ组门静脉系血栓形成１３例（３７．１４％）。结论 门静脉系统抗凝治疗是预防门静脉高压症断流术后门静脉系血栓形成的有效方法。     

低分子肝素联合华法林对门脉高压症脾切除术后门脉血栓的早期预防

目的：探讨门静脉高压症脾切除术后早期接受低分子肝素联合华法林等抗凝治疗预防门静脉血栓的疗效。方法：将2009年3月—2011年12月门静脉高压症脾切除(或)加断流术后的56例患者随机分为常规剂量服用阿司匹林的对照组（20例）及早期行低分子肝素联合华法林治疗的治疗组（36例）进行对比分析。术前两组患者的一般情况有可比性,术后第1,3,7,10,14天动态监测血小板（PLT）计数的变化,术后第1,2,4,12周行彩超或螺旋CT监测门静脉血栓（PVT）形成情况,对比分析两组临床疗效。结果：对照组发生PVT5例,发生率为25.0%;治疗组发生PVT共计1例,发生率2.7%;两组间差异有统计学意义（P<0.05）。结论：门静脉高压症脾切除（或）加断流术后患者早期接受低分子肝素联合华法林抗凝治疗是预防门静脉血栓形成的安全、有效方法。     

肝前型门静脉高压症的诊治

目的探讨肝前型门静脉高压症的临床特点、诊断、治疗方法的选择及疗效。方法回顾性分析第二炮兵总医院及北京协和医院2000年1月至2009年5月期间收治的46例肝前型门静脉高压症（包括2例Abern-ethy畸形）患者的临床资料。全部患者均根据间接门静脉造影、CT血管造影和（或）彩超检查结果确诊为肝前型门静脉高压症。行肠系膜上静脉-下腔静脉分流术23例;脾切除、脾静脉-肾静脉分流术8例;门静脉-下腔静脉分流术1例;附脐静脉-颈内静脉分流术2例;门奇静脉断流术3例;脾切除、门奇静脉断流术1例;乙状结肠暂时性造瘘,6个月后闭瘘1例;大部分小肠切除术1例;经股动脉插管溶栓4例;未行手术2例,仅给予护肝及对症治疗。结果44例患者随访2个月～5年,平均23.4个月,1例未手术者失访。34例行分流手术治疗的患者术后脾功能亢进症状消失,未再发生上消化道出血;行断流术者术后13个月及2年因再次出血行肠系膜上静脉-下腔静脉分流术2例;断流术后8个月因再次出血死亡1例;溶栓治疗后40d因肠坏死死亡1例,1例未手术的患儿出院4个月后再次出现黑便经保守治疗好转。结论肝前型门静脉高压症的治疗以降低门静脉压力为主,各种分流手术及肠系膜上动脉和（或）脾动脉置管溶栓安全有效,但需根据个体情况施行。     

贲门周围血管离断术后门静脉系统血栓形成与预防

目的 探讨乙肝肝硬化门静脉高压症患者行贲门周围血管离断术后门静脉系统血栓形成(portal vein thrombosis,PVT)的原因及诊治.方法 回顾性分析从2008年1月至2011年12月56例接受贲门周围血管离断术治疗的门静脉高压症患者的临床资料.按是否采用预防性抗凝治疗将患者分为两组,每组28例.运用Logit分析PVT形成的因素.结果 本组有9例患者发生PVT,发生率为16％,其中预防性抗凝组PVT发生率为11％,未预防性抗凝组发生率为21％.Logit回归分析:患者年龄、性别、术前血小板值和术中是否结扎脾动脉均与患者并发PVT无明显关系;而术后血小板峰值(≥300×109/L)和门静脉血流方向与患者是否并发PVT有明显关系.未预防性抗凝组PVT Ⅰ、Ⅱ、Ⅲ和Ⅳ级分别为2、3、1和0例,而预防性抗凝组PVT Ⅰ、Ⅱ、Ⅲ和Ⅳ级分别为1、2、0和0例.溶栓治疗PVT有效,经抗凝治疗后9例均顺利出院,无1例死于该并发症.结论 门静脉高压症贲门周围血管离断术后并发PVT患者中门静脉离肝性血流是决定性因素,血小板峰值≥300×109/L是重要的危险因素;其诊治关键在于早期发现和及时抗凝溶栓治疗,预防性抗凝可以明显降低PVT的发生率.     

门体断流术治疗门静脉高压症后门静脉系统血栓形成的危险因素分析

目的探讨肝硬变门静脉高压症行门体断流术后门静脉系统血栓形成(PVT)的相关危险因素。方法回顾性分析笔者所在医院2011年5月至2014年5月期间收治的40例接受脾切除+门体断流术治疗的肝硬变门静脉高压症患者的临床资料,探讨PVT发生的影响因素。结果 40例患者中,发生PVT 12例(30.00%)。多因素分析结果表明,门静脉直径、术后门静脉流速、术后2周血小板计数及术后门静脉压力均是门体断流术后PVT发生的影响因素,门静脉直径越大、术后门静脉流速越慢、术后2周血小板计数越高及术后门静脉压力越低者发生PVT的比例越高(P0.05)。结论门静脉直径、术后门静脉流速、术后2周血小板计数及术后门静脉压力均是门静脉高压症患者行门体断流术后PVT发生的主要影响因素。     

Hassab术后门静脉系统血栓形成原因及预防

目的探讨肝硬化病人行Hassab术后门静脉系统血栓形成(PVT)的原因、诊治及预防。方法对浙江大学医学院附属第一医院1999-2004年200例接受Hassab手术的病人进行回顾性分析。结果26例病人发现门静脉系统的血栓形成,发病率为13%(26/200),抗凝治疗后均顺利出院,无一例死于该并发症。结论Has sab术后并发PVT病因尚未明确,血小板峰值>300×109/L是危险因素;其诊治关键在于早期发现和及时抗凝溶栓治疗,预防性抗凝并不能明显降低发生率。     

肝移植围手术期门静脉血栓的处理

目的 探讨肝移植围手术期门静脉血栓（PVT）的处理。方法 回顾性分析中国医科大学附属第一医院1995年5月至2008年6月实施的194例肝移植病人临床资料,术前存在PVT 24例,其中Ⅰ级12例,Ⅱ级9例,Ⅲ级2例,Ⅳ级1例。术中采取不同门静脉重建方式,结扎术前存在的门腔分流和粗大的侧支循环。术后根据凝血酶原时间（PT）,应用普通肝素或低分子质量肝素预防性抗凝。术中、术后应用多普勒超声监测门静脉血供。结果 术后PVT发生率2.58%（5/194）。1例PVT经外科门静脉取栓、重新吻合治愈,3例置管溶栓、支架植入治愈,另1例仅表现肝功能轻度异常,未特殊处理。与PVT相关病死率为0。其余病例随访6~ 104个月,未见PVT。结论 理想的门静脉重建方式、结扎门腔存在的分流和术后有效的抗凝可以减少PVT的发生,多普勒超声监测能早期发现PVT,挽救移植物,避免再移植。     

肝硬化门静脉高压症术后门静脉系统血栓形成的诊治

目的探讨肝硬化门静脉高压症术后门静脉系统血栓形成（portal vein thrombosis，PVT）的临床诊断、治疗和预防。方法回顾性分析近5年来118例肝硬化门静脉高压症患者断流手术后3～5d发现的35例PVT的临床资料。结果本组PVT的发生率为29．7％。35例PVT中出现发热17例，腹泻11例，腹胀9例，呕吐咖啡样液体及黑便4例，腹痛3例，腹水2例，上消化道大出血2例，13例无临床症状。均给予低分子右旋糖酐500ml＋丹参20ml静注，每天1次；低分子肝素钙2500IU皮下注射每8小时或每12小时1次，共10～14d，尿激酶20～40万单位静脉滴注每天1次，共5～7d，出院前改华发令口服。彩色超声结合螺旋CT或磁共振血管造影检查：门静脉完全再通12例，部分再通21例，无改善2例，大出血2例，死亡1例。结论及早行彩色超声检查有助于早期诊断PVT；及早进行抗凝祛聚、溶栓治疗效果确切，有助于防止肠管坏死的发生，预防再出血，降低病死率。     

脾切除术后门静脉系血栓形成的临床诊治

目的探讨脾切除术后门静脉血栓(portal vein thrombosis,PVT)和肠系膜静脉血栓(mesenteric venous thrombosis,MVT)形成的成因及诊治策略。方法回顾分析2000年以来收治脾切除术后门静脉及肠系膜静脉血栓形成12例患者的临床资料。结果全组病例脾切除后静脉系血栓的发生率为4.3%(12/280),其中PVT发生率为3.2%(9/280),MVT发生率为1.1%(3/280)。PVT和MVT患者均出现白细胞增多,血小板计数升高,D-D二聚体检测阳性和凝血功能异常。彩色多普勒超声、增强CT检查及MRA门静脉成像确诊9例,同时行肠系膜上动脉血管造影确诊1例,因急性肠梗阻剖腹探查术确诊2例。9例经积极的全身抗凝、祛聚、溶栓治疗1～2周好转出院。2例MVT因肠坏死行小肠切除肠吻合术,术后全身抗凝、祛聚治疗,痊愈出院。1例PVT血栓急性发展至肝内门静脉,死于肝功能衰竭。结论脾切除后门静脉系统血栓形成与多种因素有关。早期诊断与及时抗凝治疗对预后有重要影响。非手术治疗效果不佳应及时手术治疗。     

脾切除术后门静脉系统血栓形成的临床分析

目的探讨脾切除术后门静脉血栓形成(portal vein thrombosis,PVT)的原因、诊断和治疗。方法对我院2002年8月至2008年8月期间收治的因肝硬变门静脉高压症及外伤脾破裂行脾切除术后发现PVT的29例患者的临床资料进行回顾性分析。结果 29例PVT患者中27例经抗凝溶栓治疗后血栓完全或部分溶解吸收、康复出院;1例因腹膜炎、感染性休克和多器官功能衰竭死亡;1例因呕血、肝昏迷及多器官功能衰竭死亡。24例患者获随访,3例失访,随访时间0.5～3年,平均2年,其中2例因大出血死亡、1例因肝性脑病死亡、1例因肝功能衰竭死亡,2例于出院1年后发生下肢深静脉血栓,其余患者未再发生静脉血栓。结论 PVT与脾切除术后血小板升高及血流动力学改变有关,手术操作规范化、早期诊断以及抗凝祛聚是防治PVT的有效方法。     

�ž�����ѹ֢���������ž���Ѫ˨�γ����η���

??Diagnosis and treatment of portal vein thrombosis in patients with portal hypertension disconnection after operation WU Jian-li, YANG Zhen, WANG Chao, et al. Department of General Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan430030, China Corresponding author??YANG Zhen, E-mail?? zyang@tjh.tjmu.edu.cn Abstract Objective To investigate diagnosis and treatment of portal vein thrombosis ??PVT??in patients with portal hypertension disconnection after operation. Methods The clinical data of 71 cases of PVT after disconnection admitted between April 1993 and October 2008 at Tongji Hospital of Tongji Medical College of Huazhong University of Science and Technology were analyzed retrospectively. Results The predilection area of postoperative PVT was splenic vein and portal vein in 9—21d after operation.Among them, except for one case died of intestinal necrosis combined toxic shock, all cases were recovered. But one case occurred in short bowel syndrome. Conclusion Abdominal doppler ultrasound or CT is the road of definite diagnosis. Operation standardization, dynamic examining platelet count, routine doppler ultrasonography or CT examining, early thrombolysis and anticoagulation therapy are the effective methods in preventing and managing PVT postoperation for potal hypertension disconnection.     

外科概念的转变-学科交叉的发展

许多疾病的治愈已经不能由单一专业的科学家来完成,需要多种方法综合治疗从而确定最佳治疗方案,为病人提供优质高效的治疗服务.学科交叉是外科学发展的必然规律和强大动力.     

腹腔镜下脾切除加贲门周围血管离断术联合术中胃镜治疗门静脉高压37例分析

目的 探讨腹腔镜下脾切除加贲门周围血管离断术（LSPD）联合术中胃镜治疗门静脉高压的临床效果。方法 回顾性分析2011年1月至2013年7月华中科技大学同济医学院附属协和医院肝胆外科收治的37例行LSPD联合术中胃镜治疗肝硬化门静脉高压并上消化道出血的病人的临床资料,分析术中出血量、手术时间、住院时间和术后并发症发生率。 结果 36例在腹腔镜下完成,1例因胃底静脉瘤破裂出血中转开腹。术毕胃镜检查23例存在残余曲张食管静脉,均行曲张静脉套扎;2例存在胃底曲张静脉,行组织胶注射。手术时间180~450 min,平均（265.2±42.5）min。术中失血100~850 mL,平均（342.0±146.5）mL。术后发生胸腔积液10例,门静脉血栓l例;难治性腹水l例,无术中及围手术期死亡。术后住院5~11 d,平均（6.5 ±2.0）d。随访3～29个月,6例失访,31例获得随访,无再出血发生。结论 LSPD是一种安全、微创、可行的手术方式,联合术中胃镜可减少术后近期再出血。     

��Ƣ������Ѫ���没�ٴ�·��̽��

??The clinical pathways of huge splenomegaly in late schistosomiasis YANG Zhen. Department of Surgery,Tongji Hospital, Tongji Medical College,Huazhong University of Science and Technology, Wuhan430030, China.
Abstract Refer to foreign latest clinical guidelines, combined with our many years of practical experience, we formulate the clinical pathways of huge splenomegaly in late schistosomiasis. The clinical pathways include diagnosis, drug therapy, endoscopy therapy, interventional therapy, surgical indications, operation methods, perioperative management, in hospital time and discharge management, nursing, follow-up, etc. We have established a new standardized flow or a pathway for surgical treatment in late schistosomiasis.     

��ǻ����Ƣ�г���������ΧѪ���������������θ�������ž�����ѹ37������

目的探讨腹腔镜下脾切除加贲门周围血管离断术(LSPD)联合术中胃镜治疗门静脉高压的临床效果。方法回顾性分析2011年1月至2013年7月华中科技大学同济医学院附属协和医院肝胆外科收治的37例行LSPD联合术中胃镜治疗肝硬化门静脉高压并上消化道出血的病人的临床资料,分析术中出血量、手术时间、住院时间和术后并发症发生率。结果 36例在腹腔镜下完成,1例因胃底静脉瘤破裂出血中转开腹。术毕胃镜检查23例存在残余曲张食管静脉,均行曲张静脉套扎;2例存在胃底曲张静脉,行组织胶注射。手术时间180~450 min,平均(265.2±42.5)min。术中失血100~850 m L,平均(342.0±146.5)m L。术后发生胸腔积液10例,门静脉血栓l例;难治性腹水l例,无术中及围手术期死亡。术后住院5~11 d,平均(6.5±2.0)d。随访3~29个月,6例失访,31例获得随访,无再出血发生。结论 LSPD是一种安全、微创、可行的手术方式,联合术中胃镜可减少术后近期再出血。     

门静脉高压症行断流术后再出血43例诊治体会

目的 探讨门静脉高压症断流术后上消化道再出血的原因及机制,总结临床诊治经验。方法 回顾性分析华中科技大学同济医学院附属协和医院肝胆外科自2012年7月至2014年12月收治因门静脉高压症行断流术后再出血43例病人临床资料。 结果 急诊手术2例,1例因胃底瘤样曲张静脉破裂出血,行胃底静脉瘤捆扎止血;另1例为弥漫性胃底贲门瘤样曲张静脉破裂出血行近端胃切除术,术后第8天死亡。择期手术10例,8例复发重度食管胃底静脉曲张行再次断流术,2例为胃底静脉瘤样曲张行近端胃切除术。15例局限性静脉曲张行内镜下治疗。其余均保守治疗。35例病人获得随访,随访时间0.5～2.5年,无一例复发出血。结论 对于门静脉高压症行断流术后再出血,应根据病因和病情,采取个体化的治疗方案。     

��ΰ����ž�����˨�����ۺ��Ʒ�ѡ������о�

??Comparison of different combined modality therapy after surgical treatment of large primary liver cancer with portal vein tumor thrombus WU Yu??ZHANG Zhi-wei??GAO Dan??et al. Hepatic Surgery Center??Tongji Hospital??Tongji Medical College??Huazhong University of Science and Technology??Wuhan 430030??China
Corresponding author??ZHANG Zhi-wei??E-mail??zwzhang@tjh.tjmu.edu.cn
Abstract Objective To study the value of surgical treatment for large primary liver cancer with portal vein tumor thrombus (PVTT) involving the main or first-order branches. Methods The clinical data of 87 large primary liver cancer patients with PVTT involving the main or first-order branches underwent hepatectomy and thrombectomy from January 2003 to December 2010 in Tongji Hospital??Tongji Medical College??Huazhong University of Science and Technology were analyzed retrospectively. The 87 patients were divided into 3 groups: group A only have hepatectomy and thrombectomy??group B have portal vein infusion chemotherapy after hepatectomy and thrombectomy??group C have transcatheter hepatic arterial chemoembolization after hepatectomy and thrombectomy. Results The 1-??2- and 3-year overall survival rates were 31.8%??12.7% and 6.4% for group A??44.7%??23.2% and 11.6% for group B and 49.0%??27.2% and 11.7% for group C??respectively. The overall survivals were significantly better in group B and group C than group A (P=0.049??P=0.033 respectively). There was no statistical significant difference in group B and group C (P=0.751). Conclusion Surgical intervention with postoperative transcatheter hepatic arterial chemoembolization or portal vein infusion chemotherapy is more effective than surgical intervention alone in treatment for large primary liver cancer with PVTT involving the main or first-order branches. However??it still needs to be carefully chosen if PVTT extends to the main trunk.     

��ͨ��Ʋ�����Ѫ�����ϰ�������

普通外科病人凝血功能障碍主要有高凝状态、血栓栓塞和低凝状态、止血障碍。可通过常规实验室检查对其进行检测,包括活化部分凝血活酶时间(APTT)、凝血酶原时间(PT)、凝血酶时间(TT)、纤维蛋白原(FIG)以及血小板(PLT)。血栓弹力图可以连续全程监测止血功能。中、重度危险的病人推荐采取药物或器械性措施,预防静脉血栓栓塞。对于出血病人,应根据床边、即时、快速试验结果和合理指征计算输入量,有针对性地输注浓缩凝血因子和新鲜冷冻血浆等血液制品。     

�ž�����ѹ֢�ж��������ٳ�Ѫ43���������

??Mechanism and experience in treatment of rebleeding after devascularization for portal hypertension: A report of 43 cases WANG Wen-jing??CAO Guo-jun??HU Qing-gang. Department of Hepatobiliary Surgery??Union Hospital??Tongji Medical College??Huazhong University of Science and Technology??Wuhan 430022??China
Corresponding author??HU Qing-gang??E-mail??18995613399@189.cn
Abstract Objective To explore the causes and mechanism of upper gastrointestinal (GI) rebleeding after pericardia devascularization in portal hypertension (PHT) in order to enhance the diagnostic level and therapeutic effects. Methods The clinical data of 43 cases of rebleeding after devascularization for portal hypertension admitted from July 2012 to December 2014 in Department of Hepatobiliary Surgery??Union Hospital??Tongji Medical College??Huazhong University of Science and Technology were analyzed retrospectively. Results Of the 2 cases by emergent operation??1 case caused by aneurysmal variceal bleeding of gastric fundus was treated by strapping of aneurysmal varicosity; 1 case of diffusivity cardia-fudus aneurysmal varicosity who was treated by proximal gastrectomy died on 8th days after surgery. Of 10 cases by selective operation??8 cases caused by recurrence of severe esophageal and gastric varices were treated by second devascularization; 2 cases of fudus aneurysmal varicosity was treated by proximal gastrectomy. A total of 15 cases of localized varicosity were treated by endoscopic therapy. The rest cases were cured by conservative treatments. No rebleeding occurred in the period of 0.5 to 2.5 years of following up in 35 cases. Conclusion For rebleeding after pericardial devascularization??individualized treatment can gain satisfactory effects.     

����ٴ��о�������������ʵʩ������ѧ����

??Employment of randomization and his reflection of ethics in surgical clinical research design YANG Zhen.Department of Surgery,Tongji Hospital, Tongji Medical College,Huazhong University of Science and Technology,Wuhan430030??China Abstract In this paper, some confliction between randomization and medical ethics in surgical clinical research design were analysed. Owing to randomization may interfere with patient’s autonomy and limit surgeons’ freedom, so randomization could be difficult to carry out in surgical clinical research. It is most important that the medical needs of the patients must always be given priority, therefore, surgeons should make good communication with patients. A few alternative design could be employed in surgical clinical research, for example the adaptive design??objective performance criteria (OPC)??sequential design and non-randomized controlled design.