脾腔静脉分流术治疗门脉高压症52例分析

我们应用脾腔静脉分流术治疗门脉高压症52例,现报告如下: 临床资料本组男43例,除1例小儿为肝外型门脉高压症外,余均为肝炎后肝硬化。肝功按Child分类属甲级40例,乙级12例。轻度腹水7例,有出血病史23例,急性大出血行分流手术者3例。手术效果:本组有45例在脾腔静脉吻合前后行大网膜静脉测门静脉压,吻合后压力下降者39例,未变者3例,上升者3例。吻合前平均压力为3.52kPa(358.8mmH_2O),吻合后平均压力为2.67kPa(271.7mmH_2O),平均降压为0.85kPa(87.1mmH_2O),吻合口大小与降压的平均值呈正相关。但也有3例吻合口直径为1.5～2.5cm者没有降压。随访:有45例随访1～6.5年,绝大部分已恢复轻工作。术前后曾做钡餐检查40例,     

脾腔静脉分流术治疗门脉高压症54例体会

脾腔静脉分流术治疗门脉高压症５４例体会沂水中心医院（２７６４００）沂水胸科医院王瑞秀董欣马金泽自１９８１年以来，我院对５４例门脉高压症患者施行脾腔静脉分流术，术后观察和随诊发现该手术方法降压效果确切，术后再出血率低，并发症少。现将治疗体会介绍如下。临...     

经颈静脉肝内门腔静脉分流术治疗门静脉高压症

经颈静脉肝内门腔静脉分流术治疗门静脉高压症顾树南陈文庆兰州军区总医院普外科甘肃省兰州市７３００５０ＳｕｂｊｅｃｔｈｅａｄｉｎｇｓＨｙｐｅｒｔｅｎｓｉｏｎ，ｐｏｒｔａｌ／ｓｕｒｇｅｒｙＰｏｒｔａｃａｖａｌｓｈｕｎｔ，ｓｕｒｇｉｃａｌＲｅｖｉｅｗｌｉ...     

门静脉高压症脾切除术后并发症的预防和治疗

门静脉高压症脾切除术后并发症的预防和治疗山东省千佛山医院（２５００１４）阮长乐脾切除手术治疗门静脉高压症已有近百年的历史。尽管如此，仍有少数患者因脾切除术中出现困难或失误而于术后发生并发症，甚至危及生命。本文结合我们对４５１例门静脉高压症患者的施术经...     

冠腔分流联合脾切除术在门静脉高压症中的应用价值

门静脉高压症是肝硬化常见且致命的并发症,其主要发病机制是门静脉系统压力的持续性升高和内脏血流高动力状态的存在,常常导致食管胃底静脉重度曲张并伴随脾大脾功能亢进[1]。我国现有慢性HBV感染者约9300万人,每年因肝硬化门静脉高压症死亡的患者数以万计。由于食管胃底曲张的静脉壁十分薄弱且仅有黏膜覆盖,因此,极容易诱发破裂出血[2]。加之患者往往合并肝炎肝硬化基础疾病,肝储备能力和凝血功能较差,且脾功能亢进使血小板明显减少,因此,出血极难控制且常常反复发生,严重时危及生命[3]。     

介入性门腔分流术治疗门脉高压症所致曲张静脉出血及腹水疗效观察

目的 评价介入性门腔分流术治疗门脉高压症所致曲张静脉出血及腹水的疗效。方法 回顾性分析2004年2月—2010年1月我院55例良性门脉高压症行介入性门腔分流术患者的临床资料,观察分流道近期和远期的通畅情况,并分析生存时间和并发症。结果 手术成功率为100%,患者门静脉压力梯度(portal pressure gradient,PPG)均达到要求,即PPG≤1.60kPa或PPG降低2.00kPa。术后1～5年生存率分别为70.4%、60.8%、60.8%、60.8%、60.8%;分流道再狭窄率分别为7.3%、13.1%、24.0%、24.0%、24.0%;消化道曲张静脉出血复发率分别为9.8%、19.3%、26.0%、26.0%、26.0%;肝性脑病发生率分别为14.8%、23.9%、35.8%、57.2%、57.2%。结论 介入性门腔分流术治疗门脉高压症所致曲张静脉出血及腹水疗效可靠。如应用覆膜支架,门腔分流道通畅率较高。肝性脑病及复发性出血等并发症的发生率较低。     

门静脉高压症的外科治疗

门静脉高压症的外科治疗王承外科治疗在门静脉高压中的作用主要是针对食管静脉曲张破裂出血。食管曲张静脉在门脉高压中的发生率随病期、病理和肝损害程度而异，据Ｐａｓｃａｌｌ９８９年报告平均为５９％（２４％～６９％）。有食管曲张静脉的病人中约１／３（１９％～４...     

脾腔分流术治疗门静脉高压症的护理

1 临床资料1982年以来,我们采用脾腔静脉分流术治疗门静脉高压症84例.男65例,女19例,年龄14—55岁.68例为血吸虫性肝纤维化;16例为混合型肝硬变.肝功能以Child分级,A级36例,B级38例,C级10例.84例均有Ⅱ-Ⅵ级脾肿大和脾功能亢进.43例有消化道出血史,出血3次以上者11例,其中有1例反复出血达15次之多.食管钡餐造影68例有不同程度的静脉曲张,有7例虽未发现静脉曲张,但术前都有3次以上出血史,采用脾腔侧侧分流术62例,脾腔端侧分流术22例.2 护理体会2.1 心理护理门静脉高压症患者病情复杂,并常伴有其它系统疾病,集中表现为体质弱,食欲欠佳,患者精神紧张、恐惧、顾虑重重、担心手术顺利与否等.针对患者     

TH胶胃冠状静脉栓塞,脾切除治疗门静脉高压症

我院自1988年6月采用西安化工研究所研制的α-氰基丙烯酸正辛脂(简称TH胶)行胃冠状静脉栓塞+脾切除术治疗门静脉高压症26例,取得了满意的效果,现报告如下。一、临床资料男18例,女8例。年龄6～65岁。病史2～25年。病人均有不同程度的食道胃底静脉曲张。有出血史者22例。肝功能按Chird分级,A级5例、B级13例、C级8例。择期手术24例,急诊手术2例。取肝组织活检者     

切脾加分流术治疗血吸虫病门脉高压症远期随访

目的：观察脾切除术附分门体分流术治疗血吸虫病肝纤维化门脉高压症的远期效果。方法：术后每年由基层血防专业人员随防记录,每隔5－10年由外科医师检查,重点记录存活率、死亡原因及有关并发症。结果：所有病例分别随访5－10、11－20、21－30、31－40年,生存率分别为73．7％、61．5％、49．2％、32．8％,比较各分流术式结果,以脾腔分流为佳。结论：血吸虫病肝纤维化如有食道静脉曲张出血倾向者,手术治疗以脾切除附加脾腔端侧分流术为首选。     

Effects of modified splenocaval shunt plus devascularization on esophagogastric variceal bleeding: a comparative study of this treatment and devascularization only in cirrhotic portal hypertension

Background

Pericardial devascularization (PCDV) and portosystemic shunt were reported to have favorable results for the management of portal hypertension in cirrhotic patients in China and the West, respectively. This study was undertaken to investigate the effects of a modified proximal splenocaval shunt plus PCDV on variceal bleeding in patients with portal hypertension.

Methods

From January 1997 to December 2007, 168 patients with portal hypertension of cirrhotic origin received an operation for gastroesophageal variceal bleeding. Of these, 90 patients received a splenocaval shunt plus a PCDV procedure (Combined Group) and the other 78 patients received a PCDV procedure only (PCDV Group). The procedure-related morbidity and mortality, rebleeding, encephalopathy, and survival rates were analyzed.

Results

Postoperative mortality was 3.3% in the combined group and 5.1% in the PCDV group (P > 0.05). Overall morbidity was 13.3% in the combined group and 15.4% in the PCDV group (P > 0.05). The rate for rebleeding, including variceal bleeding and gastropathy, was 5.1% in the combined group, which was significantly lower than that in the PCDV group, at 16.7% (P < 0.05). The incidence of encephalopathy was 6.63% in the combined group and 6.67% in the PCDV group (P > 0.05). The 1-, 3-, 5- and 10-year survival rates were 97.4, 91.7, 80.0, and 60.0% in the combined group and 96.7, 83.3, 73.3, and 53.3% in the PCDV group (P > 0.05).

Conclusions

The modified splenocaval shunt plus PCDV is a safe and effective procedure for the long-term control of variceal bleeding; the procedure may not only maintain the portal flow to the liver, but may also protect the liver function in cirrhotic patients. The better clinical outcome means that the procedure may be one of the best choices for treating portal hypertension of cirrhotic origin.     

经颈静脉肝内门体静脉分流术治疗肝硬化门静脉高压共识意见

<正>门静脉高压症是肝硬化发展过程中的重要病理生理环节,也是肝硬化失代偿期的重要临床表现之一。经颈静脉肝内门体静脉分流术(transjugular intrahepatic portosystemic shunt,TIPS)通过在肝静脉与门静脉之间的肝实质内建立分流道,以微创的方式,从结构上显著降低门静脉阻力,是降低肝硬化患者门静脉压力的关键措施之一。选择恰当病例,可有效减少食管胃静脉曲张再出血和腹水复发等肝硬化并发症,改善肝硬化患者生活质量,减少或延缓对肝移植的需求[1-3]。TIPS应用于临床已有20余年,在经历了一系列观念、技术、器材和联合药物治疗的探索后,目前该技术的有效性和安     

Distal splenorenal shunt versus transjugular intrahepatic portal systematic shunt for variceal bleeding: a randomized trial

BACKGROUND & AIMS: Variceal bleeding refractory to medical treatment with beta-blockers and endoscopic therapy can be managed by variceal decompression with either surgical shunts or transjugular intrahepatic portal systemic shunts (TIPS). This prospective randomized trial tested the hypothesis that patients receiving distal splenorenal shunts (DSRS) would have significantly lower rebleeding and encephalopathy rates than TIPS in management of refractory variceal bleeding. METHODS: A prospective randomized controlled clinical trial at 5 centers was conducted. One hundred forty patients with Child-Pugh class A and B cirrhosis and refractory variceal bleeding were randomized to DSRS or TIPS. Protocol and event follow-up for 2-8 years (mean, 46 +/- 26 months) for primary end points of variceal bleeding and encephalopathy and secondary end points of death, ascites, thrombosis and stenosis, liver function, need for transplant, quality of life, and cost were evaluated. RESULTS: There was no significant difference in rebleeding (DSRS, 5.5%; TIPS, 10.5%; P = .29) or first encephalopathy event (DSRS, 50%; TIPS, 50%). Survival at 2 and 5 years (DSRS, 81% and 62%; TIPS, 88% and 61%, respectively) were not significantly different (P = .87). Thrombosis, stenosis, and reintervention rates (DSRS, 11%; TIPS, 82%) were significantly (P < .001) higher in the TIPS group. Ascites, need for transplant, quality of life, and costs were not significantly different. CONCLUSIONS: DSRS and TIPS are similarly efficacious in the control of refractory variceal bleeding in Child-Pugh class A and B patients. Reintervention is significantly greater for TIPS compared with DSRS. Because both procedures have equivalent outcomes, the choice is dependent on available expertise and ability to monitor the shunt and reintervene when needed.     

Combined splenocaval or mesocaval C shunt and portoazygous devascularization in the treatment of portal hypertension: analysis of 150 cases

BACKGROUND: Portal hypertension is a common disease and its major surgical therapeutic approaches include devascularization and shunting. This study was undertaken to investigate the effects of combined splenocaval or mesocaval C shunt and portoazygous devascularization (combined procedures) on portal hypertension. METHODS: The clinical data of 150 patients with portal hypertension who had undergone combined procedures at the First Affiliated Hospital of Zhengzhou University from May1990 to May 2003 were analyzed retrospectively. RESULTS: The mean free portal pressure (FPP) was 25.6±1.83 mmHg, 18.0±2.07 mmHg and 18.4±2.19 mmHg before operation, after splenectomy plus splenocaval or mesocaval C shunt, and combined procedures, respectively. There was no operative death in all patients. The 1-7 year follow-up of 100 patients showed rebleeding in 3 patients, encephalopathy in 4, thrombosis of artificial vascular graft in 3, and dying from liver failure in 2. CONCLUSIONS: The combined procedures can not only decrease portal pressure but also preserve hepatic blood flow to some extent. It may be one of the best choices for treating portal hypertension in China.     

Effects of transjugular intrahepatic portosystemic shunt treatment of patients with liver cirrhosis and portal hypertension: Case series

Rationale:Transjugular intrahepatic portosystemic shunt (TIPS) is well established as an effective treatment tool for portal hypertension. However, the effects of TIPS in patients with liver cirrhosis and portal hypertension have not been adequately verified in clinical trials.Patient Concerns:To evaluate the effects of TIPS in patients with liver cirrhosis and portal hypertension with or without portal vein thrombosis (PVT).Interventions:A total of 55 patients with liver cirrhosis and portal hypertension received TIPS treatment from December 2014 to April 2018 were enrolled. Clinical data, including portal pressure, Child-Pugh score, and relevant complications were recorded.Outcomes:TIPS was successfully performed in 54 patients. The overall technical success rate was 98.19% without serious technical complications. After TIPS treatment, portal pressure was significantly reduced from 38.13 ± 4.00 cmH₂O to 24.14 ± 3.84 cmH₂O (P < 0.05). In addition, symptoms including gastrointestinal bleeding and ascites were improved after TIPS treatment. During the 6 to 21-month follow up, hepatic encephalopathy in 15 patients (27.8%), shunt dysfunction in 5 patients (9.3%), rebleeding in 12 patients (22.2%) and deterioration of liver function in 2 patients (3.7%) were recorded. Moreover, there were no significant differences in the rates of rebleeding and hepatic encephalopathy between patients with PVT and the non-PVT group, whereas the occurrence rate of TIPS dysfunction was higher in the PVT group, but not statistically significant.Lessons:TIPS treatment could alleviate the symptoms of liver cirrhosis and portal hypertension in individuals with or without PVT. However, complications during follow-up should be appropriately noted and addressed with corresponding treatments.     

Effect of shunt surgery on spleen size, portal pressure and oesophageal varices in patients with non-cirrhotic portal hypertension

Shunt surgery is considered to be the treatment of choice in patients with non-cirrhotic portal hypertension. There is little data on the effect of side-to-side lieno-renal (SSLR) shunt on oesophageal variceal size, splenic size and splenic pulp pressure (SPP) in patients with non-cirrhotic portal hypertension. We evaluated pre- and postoperatively endoscopic grading of varices, splenic size and SPP for predicting shunt patency in 86 patients with non-cirrhotic portal hypertension: 56 with extrahepatic portal venous obstruction (EHPVO) and 30 with non-cirrhotic portal fibrosis (NCPF). The EHPVO patients with patent shunts (n= 47) showed significant reduction in SPP (pre-operative 43.56±7.9 vs postoperative 29.96±7.7 cm of saline), splenic size (6.5±2.8 vs 4.00±2.6 cm below costal margin) and varices grades (2.96±0.5 vs 0.92±0.8). Patients with blocked shunt (n= 9) did not show significant reduction in SPP and varices grades. However, there was reduction in spleen size (8.6±3.0 vs 6.3±4.3). In the NCPF group, 28 had patent shunts and showed significant reduction in SPP (46.3±13.5 vs 33.8±7.6 cm of saline), splenic size (9.1±3.3 vs 6.8±4.6 cm below costal margin) and varices grades (2.8±0.7 vs 1.05±0.96). As only two patients with NCPF had blocked shunts, no statistical comparison between patients with patent and patients with blocked shunts could be done. In conclusion, following SSLR, there is a significant reduction in SPP and varices grades in patients with patent shunts. Endoscopic grading of varices can be used to predict shunt patency. However, spleen size is not a good criteria for predicting shunt patency.     

经颈静脉肝内门体分流术研究进展及其在肝硬化门静脉高压治疗中的应用

近年来,随着基础研究及临床应用的进步,经颈静脉肝内门体分流术(TIPS)的成功率明显提高,支架再狭窄率及术后肝性脑病的发生率亦得到控制。结合笔者临床实践及国内外大会热点,就TIPS相关技术进展及其在肝硬化中的应用进行介绍,主要包括TIPS穿刺辅助技术、TIPS支架、TIPS相关肝性脑病及防治以及TIPS适应证和禁忌证、TIPS在肝硬化中解决的问题、肝硬化食管胃底静脉曲张破裂出血治疗中TIPS相对于其他治疗方法的优缺点。以期为TIPS更好的发展作一点贡献,让更多肝硬化患者获益。     

Management of portal hypertension based on portal hemodynamics

Portal hypertension is most commonly caused by chronic liver disease. As liver damage progresses, portal pressure gradually elevates and hemodynamics of the portal system gradually change. In normal liver, venous returns from visceral organs join the portal trunk and flow into the liver (hepatopetal blood flow). As portal pressure increases due to liver damage, congestion of some veins of the visceral organ occurs (blood flow to and from). Finally, the direction of some veins (the left gastric vein in particular) of the visceral organ change (hepatofugal blood flow) and develop as collateral veins (portosystemic shunt) to reduce portal pressure. Therefore, esophagogastric varices serve as drainage veins for the portal venous system to reduce the portal pressure. In chronic liver disease, as intrahepatic vascular resistance is increased (backward flow theory) and collateral veins develop, adequate portal hypertension is required to maintain portal flow into the liver through an increase of blood flow into the portal venous system (forward flow theory). Splanchnic and systemic arterial vasodilatations increase the blood flow into the portal venous system (hyperdynamic state) and lead to portal hypertension and collateral formation. Hyperdynamic state, especially around the spleen, is detected in patients with portal hypertension. The spleen is a regulatory organ that maintains portal flow into the liver. In this review, surgical treatment, interventional radiology, endoscopic treatment, and pharmacotherapy for portal hypertension (esophagogastric varices in particular) are described based on the portal hemodynamics using schema.     

肝前性门静脉高压症：9年诊治经验

目的探讨肝前性门脉高压综合征（PPH）诊断、临床特征、治疗方法的选择和疗效观察。方法回顾分析PPH40例患者的临床资料,依照间接门静脉造影和/或门静脉系统CT血管成像,全部确诊为PPH。施肠系膜上静脉-下腔静脉转流术31例,脾切除、脾静脉-肾静脉转流术4例,门静脉-下腔静脉转流术1例,肠系膜上静脉门静脉探查术、门奇静脉断流术2例,未行手术2例,仅给与保肝等内科治疗。结果 39例术后随访3个月～8年,1例未手术患者失访。36例经肠腔、脾肾和门腔转流手术治疗的患者术后脾亢消失,未再发生上消化道出血;2例断流手术患者,术后8月1例死亡,2例保守治疗1例死亡。结论间接门静脉系造影或CT门静脉系血管成像检查是诊断PPH的标准方法,分流手术安全有效。