胰源性肝外门静脉高压症八例

目的总结胰源性左侧肝外门静脉高压症（LEPH）临床特点、诊断和治疗经验.方法回顾性分析我院收治的8例LEPH病人临床资料.结果LEPH主要表现为黑便、呕血和脾肿大、脾功能亢进,并有胰腺炎、胰腺肿瘤或胰腺外伤表现,而无肝脏疾病表现,内镜下以孤立性胃底静脉曲张为主.术前易误诊为肝硬化门脉高压症.本组病例中行单纯脾切除2例,脾切除＋胰体尾切除术5例,脾动脉结扎1例.结论胰腺疾病可致门静脉高压症,脾静脉栓塞是本病直接原因.胰腺疾病合并上消化道出血应想到本症可能,脾切除术可有效控制出血.     

胰源性区域性门静脉高压症12例分析

区域性门静脉高压症亦称为“左侧门静脉高压”、“局限性门静脉高压”等,是指无肝硬化的高压症,涉及肠系膜上静脉、脾静脉或整个脾肠系膜静脉门脉轴继发性病变。区域性门静脉高压根据病因可分为胰源性、脾源性和腹膜后源性三类,其中以胰源性最常见。胰源性中又以慢性胰腺炎最为常见。我院自1995年1月至2004年12月间共收治胰源性门静脉高压12例,现分析如下。     

胰源性门静脉高压症21例诊治经验

目的:探讨胰源性门静脉高压症的诊断方法和治疗措施.方法:回顾分析我院自1995年3月至2006年6月收治的胰源性门静脉高症症21例,均有胰腺炎病史,其中3例合并假性囊肿,1例合并胰尾部癌.10例有上消化道大出血.结果:16例行手术治疗.手术指征:胃底静脉重度曲张或伴有食道静脉曲张,既往有上消化道大出血史,以及门静脉主干有血栓形成.手术方法:脾切除是基本方法,胰周纤维化明显者联合胰体尾切除;假性囊肿行囊肿-空肠Roux-en-v式吻合;胰尾癌行胰体尾切除;有食管静脉曲张者附加贲门食管周围血管离断术;门静脉主干有血栓者行肠系膜上静脉-下腔静脉H型分流术.5例行非手术治疗.结论:胰源性门静脉高压症临床较为少见,其诊断和治疗有不同于肝硬化性门静脉高压症的特点,手术治疗效果良好.对于胃底静脉曲张较轻、无出血史者可非手术治疗,随着胰腺原发病的控制和血栓再通,胃底静脉曲张也可好转或停止发展.     

胰源性门静脉高压症1例并文献复习

胰源性门静脉高压症(pancreatic sisstral portal hyperten-sion,PSPH)是一种特殊类型的肝前型门静脉高压症,亦称为"左侧门静脉高压症"或"区域性门静脉高压症",约占肝外型门静脉高压症的5%[1].PSPH是由胰腺原发疾病引起脾静脉受压、闭塞、回流障碍,使脾脏淤血肿大、脾功能亢进和脾胃区门静脉压力升高,而门静脉主干压力和肠系膜上静脉压力正常,可造成胃黏膜下静脉曲张,继而可发生上消化道出血[2].在复习相关文献基础上,现将我院收治1例手术病例报告如下.     

腹腔广泛淋巴结结核钙化致胰源性门静脉高压症1例

胰源性门静脉高压症（Pancreatic sinistral potal hypertension，PSPH）是一种特殊类型的肝前型门静脉高压症，亦称为“左侧门静脉高压症”或“局限性门静脉高压症”，约占肝外型门静脉高压症5％。该病是由于脾静脉血回流受阻所引起的胃脾区域静脉压力增高，造成胃黏膜下静脉曲张，继而可发生上消化道出血，是上消化道出血少见原因之一，临床医生对此症认识不足，常常误诊和漏诊。而腹腔内广泛淋巴结结核钙化压迫脾静脉致门静脉高压临床更为罕见，现将作者遇见一例报告如下。     

胰源性门静脉高压症的诊断与治疗

目的 总结胰源性门静脉高压症的诊断与治疗经验.方法 回顾性分析40例胰源性门静脉高压症患者的临床表现、诊治和疗效.结果 本组40例患者中男26例,女14例,平均年龄(40±10)岁;16例合并上消化道出血,20例合并脾功能亢进;胰体尾良性肿瘤16例,恶性肿瘤6例,重症胰腺炎合并胰腺假性囊肿8例,慢性胰腺炎10例.胰源性门静脉高压组脾静脉压力为(28.4 ±4.2)cm H2O,与对照组相比差异有统计学意义,P＜0.01.Doppler超声测定脾静脉直径和流速分别为(1.3±0.2) cm和(9.3±0.5)cm/s,与对照组相比差异有统计学意义,分别P＜0.01、P＜0.05.36例行手术治疗,其中20例因脾功能亢进行脾切除,有2例加行贲门周围血管离断术,其余16例针对原发疾病行外科处理.另4例行内镜硬化治疗.随访率为100％.患者术后预后佳,无上消化道出血复发.结论 超声、CT和内镜检查结合患者的临床表现,诊断胰源性门静脉高压症并不困难.治疗策略既要解决区域性门静脉高压症,又要针对原发病灶.     

胰腺炎后胰源性门静脉高压患者术中大出血的危险因素探究

目的分析胰腺炎后胰源性门静脉高压患者术中大出血的危险因素并探讨其应对策略。方法回顾性分析2015年1月至2018年3月期间四川大学华西医院收治的胰腺炎后胰源性门静脉高压患者的临床资料。术中大出血定义为失血量超过30%血容量。与术中大出血密切相关的因素采用向前法的二分类logistic回归模型分析。结果本研究共纳入128例胰源性门静脉高压患者,其中男104例,女24例;平均年龄47岁,中位术中出血量482 m L。其中由急性胰腺炎后胰腺假性囊肿所致者93例,因慢性胰腺炎所致者35例。有上消化道出血病史者36例,合并脾功能亢进者46例。发生术中大出血患者36例,其中30例为实施胰体尾+脾切除术患者、1例为保留十二指肠胰头切除术患者、有5例为行假性囊肿引流术患者。单因素分析结果显示,胰腺炎后胰源性门静脉高压患者发生术中大出血与患者的性别、年龄、体质量指数、白蛋白水平、上消化道出血、脾功能亢进、胰腺炎类型、胰腺炎病程、胰腺炎发作次数、脾脏体积、脾静脉阻塞部位病变最大径及手术次数均无关(P0.05),而与曲张静脉最大直径≥5.0 mm(χ~2=19.83,P0.01)、腹腔内曲张静脉分布区域(χ~2=13.67,P0.01)、脾静脉阻塞部位(χ~2=5.17,P=0.03)、手术时间(t=–3.10,P0.01)及切除脾脏(χ~2=17.46,P0.01)有关;进一步进行logistic回归分析结果发现,曲张静脉最大直径≥5.0 mm(OR=6.356,P=0.002)和切除脾脏(OR=4.297,P=0.005)为胰腺炎后胰源性门静脉高压患者术中大出血的独立危险因素。结论胰腺炎后胰源性门静脉高压患者术中大出血的独立危险因素为曲张静脉直径≥5.0 mm和切除脾脏,术前应对曲张静脉直径进行密切关注,对于切除脾脏选择时应进行优化,有望控制术中大出血的发生。     

胰源性门静脉高压症治疗进展

胰源性门静脉高压症（pancreatic sinistral portal hypertension,PSPH）是由胰腺疾病导致脾静脉回流受阻而引起的一种临床综合征,其病因主要包含急、慢性胰腺炎,胰腺肿瘤以及胰腺手术相关的医源性因素。PSPH患者大多表现为孤立性胃静脉曲张、脾肿大和脾功能亢进,肝功能多正常,胃底曲张静脉破裂所致上消化道出血为其最严重的临床表现。PSPH的治疗可分为脾胃区门静脉高压症的治疗,包括密切随访、药物治疗、内镜治疗、脾动脉栓塞术、脾切除术等;对胰腺原发疾病的治疗主要针对急性、慢性胰腺炎以及胰腺肿瘤;特别是与胰腺手术术式相关的PSPH值得关注。     

胰源性门静脉高压症并上消化道出血的诊治体会

目的探讨胰源性门静脉高压症并上消化道出血的诊断及治疗方式。方法回顾性分析2014年6月至2018年6月期间笔者所在医院诊治的13例胰源性门静脉高压症并上消化道出血患者的临床资料。结果 2例早期行内镜下治疗,因再发上消化道出血行手术治疗;11例早期明确诊断后行手术治疗。所有行手术治疗的患者术后恢复顺利,无并发症发生。术后均获访,随访时间6～24个月,中位数为18个月,随访期间无患者死亡及失访病例,未再发消化道出血等并发症。定期复查胃镜及腹部CT检查,曲张胃底静脉情况明显改善。结论对胰源性门静脉高压症并上消化道出血患者,早期明确诊断是关键,应选择针对胰腺疾病的相应手术治疗方案。脾切除术联合胃底血管离断术是治疗胰源性门静脉高压症并上消化道出血的有效手术方式。     

对胰源性门静脉高压症的认识

胰源性门静脉高压症又名胰源性区域性门静脉脉高压症．又称为左侧肝外门静脉高压症（1eftsided extrahepatic portal hypertension，LEPH），指脾静脉血回流受阻引起的胃脾区域静脉压力增高，造成胃黏膜下静脉曲张，继而可发生上消化道出血，是上消化道出血少见原因之一．临床医师对此病认识不足，常造成误诊和漏诊，现就此认识浅谈如下。     

Recognition and clinical implications of mesenteric and portal vein obstruction in chronic pancreatitis

While splenic vein obstruction is a well-described feature of chronic pancreatitis, analogous occlusion of the superior mesenteric and/or portal veins (SMV-PV) has not been appreciated. We present 14 instances of SMV-PV obstruction in patients with proved chronic pancreatitis without cancer. Portal hypertension was first suspected because of variceal bleeding (4/14) or unexpected varices at laparotomy (10/14). The angiographic appearance mimicked that of pancreatic cancer. The splenic vein was also occluded in eight of the 13 patients who had angiograms. The liver was normal in all 14 cases. The clinical importance of SMV-PV occlusion in chronic pancreatitis lies in (1) its presentation by variceal bleeding, (2) the probable necessity for nonshunting means of control for bleeding varices, (3) the increased difficulty of operations on the pancreas because of portal hypertension, and (4) the possible confusion with pancreatic cancer.     

区域性门静脉高压症的诊断及治疗(附五例报告)

目的 探讨区域性门静脉高压症的诊断及治疗方法.方法 回顾性分析我院1992年～2002年诊治的区域性门静脉高压症5例的临床资料.本组5例均行手术治疗.结果 本组无并发症发生,无手术死亡病例.术后随访5年,2例肿瘤病人在1年内死亡,其余3例未发生消化道出血.结论 对于未发现肝脏疾病而有胃底静脉曲张、脾功能亢进的病人,应考虑本病.本病可经脾切除加贲门周围血管离断术治愈.     

Splanchnic venous obstruction. A complication of chronic pancreatitis

A retrospective review of 20 adult patients with splanchnic venous obstruction secondary to chronic pancreatitis was performed to identify factors important in the preoperative diagnosis and operative management of this disorder. Fifteen patients with isolated splenic vein obstruction, four with portal occlusion and one with isolated inferior mesenteric vein occlusion were studied. Chronic alcoholism was the etiology of the pancreatitis in 18 patients; two patients had a Type IV hyperlipidemia. Four patients with massive hemorrhage from gastric varices were treated with splenectomy. Most patients presented with complaints of chronic pancreatitis, requiring pancreaticojejunostomy to treat the underlying pancreatic disorder. Splenic artery inflow control was obtained preoperatively in six patients and offers a technique that is beneficial in decreasing operative blood loss. The dynamic computerized tomography (CT) scan was a valuable diagnostic tool in identifying splanchnic venous obstruction although selective angiography is required for confirmation of the diagnosis.     

肠系膜静脉血栓的介入治疗

目的探讨经肠系膜上动脉灌注罂粟碱和经皮经肝肠系膜静脉取栓和／或溶栓联合治疗肠系膜静脉血栓（MVT）的价值。方法回顾分析北大三院经介入诊治的9例MVT。9例患者均行血管造影检查和超声检查，其中5例行CT检查，2例行MR检查。患者从就诊到明确诊断接受介入治疗的时间间隔为15～168小时。明确诊断MVT后即经外周静脉给予肝素抗凝治疗；9例MVT均行经肠系膜动脉灌注罂粟碱治疗，其中8例同时行经皮经肝门静脉、肠系膜上静脉取栓和溶栓治疗。2例怀疑肠坏死介入治疗后行外科肠切除术。结果本组9例MVT中2例血栓局限在肠系膜上静脉内；7例血栓延及门静脉或脾静脉。9例患者7例治愈；1例不明原因猝死；1例因门脉高压行门腔静脉分流术后肝功衰竭死亡。结论经肠系膜动脉灌注罂粟碱联合经皮经肝门静脉、肠系膜静脉取栓和／或溶栓是治疗MVT的有效方法。     

Percutaneous revascularization of reoccluded meso-Rex shunts in extrahepatic portal vein obstruction

Extrahepatic portal vein (PV) obstruction (EHPVO) is a rare disorder in early childhood with unknown incidence and mostly unknown etiology. In children with EHPVO, the hepatopedal flow of the mesenteric venous blood is hindered by an obstruction of the PV resulting in prehepatic portal hypertension. The curative treatment with a meso-Rex shunt connects the superior mesenteric vein to the left PV by a venous autograft. Despite good primary patency, reocclusion of a meso-Rex bypass and its treatment can be challenging. We present 2 patients with EHPVO with subtotal functional occlusion of a meso-Rex shunt treated by percutaneous interventions with short- and mid-term follow-up.     

儿童肝外型门脉高压症的诊治

目的 探讨儿童肝外型门脉高压症的临床分型和治疗经验。方法 回顾30例门脉高压症患儿，肝前性门脉高压13例(43．3％)，肝后性即布加综合征17例(56．7％)。手术治疗20例，保守治疗10例。结果 20例手术治疗患儿治愈好转18例(90％)。其中肝前性门脉高压手术治疗10例，治愈好转10例(100％)；布加综合征手术治疗10例，治愈好转8例(80％)，手术后死亡2例(20％)。保守治疗10例：2例布加综合征人院后死亡，自动出院8例。结论 儿童肝外型门脉高压症临床分型为肝前性和肝后性，以手术治疗为主，肝前性门脉高压症治疗效果和预后明显好于肝后性。     

Parastomal ileal conduit hemorrhage and portal hypertension.

An analysis of six cases of parastomal ileal conduit hemorrhage in patients with portal hypertension is presented. The presence of coexisting esophageal varices, documented in only one of six cases (17%), suggest preferential retrograde portal flow through mesenteric venous (as opposed to coronary-azygos) collateral channels. Venous phase mesenteric angiography offers the best diagnostic specificity and provides inferential evidence regarding overall liver blood flow. Operative therapy should be based on assessment and understanding of the splanchnic circulatory derangements which accompany intrahepatic portal obstruction.     

肝前性门脉高压症

目的 探讨肝前性门脉高压症的临床特点及治疗方法的选择。方法 ２例非肝硬化门脉纤维化,８例肝外门脉阻塞,隔膜切除１例,自体血管钎肠系膜上静脉→门静脉搭桥１例,肠腔分 ３例,脾切除脾脏脾肾分流５例。结果 １例死亡,９例治愈。结果 肝前生门脉高压症在临床表面方面有许多不同,分流术可作为基本手术,病变血管的矫正术更合理。     

Hepatic haemodynamic changes after portacaval anastomosis in normal, cirrhotic and chronic prehepatic portally hypertensive rats

Radioactive microspheres were used to determine the hepatic haemodynamic response to portacaval anastomosis in normal, cirrhotic and chronic prehepatic portally hypertensive rats 20 days after operation, and in normal rats 2 months after operation. After 20 days portacaval anastomosis caused a decrease in liver mass only in normal and cirrhotic animals, whereas hepatic arterial blood flow per unit of mass increased in normal (+488 per cent), cirrhotic (+191 per cent) and prehepatic portally hypertensive rats (+133 per cent). Despite these facts, animals with portacaval anastomosis showed a reduced hepatic total perfusion (arterial plus portal inflow) per unit of mass with respect to controls in normal (-53 per cent) and cirrhotic rats (-68 per cent), but not in those with prehepatic portal hypertension. Comparing studies carried out at 2 months with those performed 20 days after portacaval anastomosis in normal rats, some recovery of liver mass and total liver blood flow was observed. In conclusion, portacaval anastomosis produced a limited increase in hepatic arterial blood flow which was unable to preserve liver mass and its total perfusion in normal and cirrhotic animals. In contrast, portacaval anastomosis did not significantly alter liver mass or its perfusion in animals with chronic prehepatic portal hypertension, as both values were previously diminished in controls. Thus, the risk of liver failure after portacaval anastomosis is higher in normal and cirrhotic rats than in those with chronic prehepatic portal hypertension.     

Management of recurrent hemorrhage in portal hypertension

123 cases of recurrent hemorrhage were studied. It was found that the rebleeding rate differed with different original operations. Those with unsatisfactory portal decompression or persistence of varices were prone to rebleeding. Rebleeding within one year occurred in 47.96%, and in late stage in 52.04%. Early postoperative rebleeding should be treated conservatively with intensive circulatory resuscitation. Repeated rebleeding occurred in 89% of the patients, reoperation should be carried out with definite indications. Emergency surgery was usually not recommended. On the operation, portal vein thrombosis was found in 58.8% of the patients, and dilatation of the superior mesenteric vein in 82.9%. Of the fifty six rebleeding cases treated surgically, 21.4% died of further bleeding in 5 years compared with 50.7% treated conservatively. Rebleeding occurred in 62.5% of disconnection cases and in 31.2% of shunt cases. The authors performed mesocaval side-to-side anastomosis in those with enlarged superior mesenteric vein, and restricted portocaval shunt in those without portal thrombosis. Rebleeding patients with regional portal hypertension were better treated with devascularization.