门静脉血栓形成对肝硬化病程发展影响

目的探讨门静脉血栓（PVT）形成对肝硬化病程的影响。方法回顾我院2003年～2011年肝硬化伴PVT形成的患者资料。18例肝硬化伴PVT形成患者人选血栓组;随机选择同阶段肝硬化门静脉高压症的无门静脉血栓形成患者19例作为对照组,比较两组患者的门静脉宽度、脾脏厚度、食管胃底静脉曲张、腹水及上消化道大出血发生等情况。结果血栓组的门静脉宽度及脾脏厚度大于对照组,差异有统计学意义（P〈0．05）。血栓组食管胃底重度静脉曲张、上消化道大出血和大量腹水比例两组比较,差异有统计学意义（P〈0．05）。结论脾肿大和门静脉增宽是PVT形成的主要危险因素,PVT形成加重门静脉高压的程度,从而增加上消化道出血几率,使腹水难以消退,增加相关并发症发生率并使相关症状加重,预防门静脉血栓形成有助于延缓肝硬化病情发展。     

肝硬化门静脉血栓形成的临床分析

目的　探讨肝硬化 (LC)门静脉血栓 (PVT)形成对LC病程发展的影响。方法　检索我院自 1 995至 2 0 0 2年肝硬化PVT形成患者 ,血栓诊断依据彩色多普勒和 (或 )CT。 4 8例肝硬化PVT形成患者入选血栓组 ;同阶段LC门脉高压症的非血栓病例中选择 5 2例作为对照组。对两组患者的肝功能Child Pugh分级、凝血功能、门静脉、脾静脉宽度及脾脏面积、厚度进行比较。行t检验 ,χ2 检验 ,Logistic回归分析。结果　肝硬化PVT形成除继发于脾切除等手术后 ,75 .0 %隐匿发病 ,85 .4 %的血栓发生于门静脉主干 ,脾脏增大与门静脉增宽是PVT形成的危险因素 (P =0 .0 0 3、0 .0 1 0 )。血栓组门静脉及脾静脉宽度分别为 (1 .4 8± 0 .2 6 )cm ,(1 .2 3± 0 .38)cm ,与对照组比较差异有显著性 [(1 .37± 0 .2 2 )cm ,(1 .0 5± 0 .30 )cm ,P =0 .0 37,0 .0 31 ]。血栓组脾面积平均值为 (96 .6 4± 33.4 )cm2 ,脾厚径为 (6 .0 7± 1 .2 0 )cm ,分别大于对照组的 (80 .81± 2 8.9)cm2 ,(5 .2 3± 1 .0 8)cm(P =0 .0 36 ,0 .0 0 1 )。血栓组食管胃底静脉曲张程度重于非血栓组 ,大出血、大量腹水比例高 (P <0 .0 5 )。血栓形成后 1年内死亡率为1 6 .6 % ,较非血栓组增高 (P =0 .0 2 3)。两组肝功能Child Pugh分级、凝血功能、血小板计     

Retrospective evaluation of risk factors of postoperative varices after pancreaticoduodenectomy with combined portal vein resection

BackgroundCombined portal vein (PV) resection is performed for pancreatic head cancer to achieve clear resection margins. This can be complicated by the formation of varices due to sinistral portal hypertension after pancreaticoduodenectomy (PD) with combined PV resection. However, clinical strategies to prevent varices formation due to sinistral portal hypertension remain controversial. Moreover, the critical vein among splenic vein (SPV), inferior mesenteric vein, left gastric vein, or middle colonic vein requiring preservation to prevent the development of varices remains unclear.MethodsWe retrospectively analyzed patients with pancreatic cancer who underwent PD with combined PV resection over 18 years at our institution. Varices were evaluated using enhanced computed tomography (CT) and endoscopy. Preoperative types of porto-mesenterico-splenic confluence, venous drainage, and venous resection types were determined by operative records and CT findings.ResultsOf the 108 subjects, the incidence of postoperative varices was observed in 24.1% of cases over 5.6 months. These varices were classified into five types based on location, as pancreaticojejunostomy anastomotic (11.5%), gastrojejunostomy anastomotic (11.5%), esophageal (11.5%), splenic hilar-gastric (23.1%), and right colonic (65.4%) varices. No case of variceal bleeding occurred. Multivariate analysis showed SPV ligation as the greatest risk factor of varices (P < 0.001), with a higher incidence of left-sided varices in patients with all the SPV venous drainage sacrificed (60%) than in the others (16.7%). Therefore, sacrificing all the SPV venous drainage was the only independent risk factor of varices (P = 0.049).ConclusionsPreservation of SPV venous drainage should be considered during SPV ligation to prevent post-PD varices.     

检测门脉高压程度评估肝硬化严重程度研究进展

<正>肝硬化是由一种或多种原因引起的、肝组织弥漫性纤维化、假小叶和再生结节为组织学特征的进行性慢性肝病,临床以门静脉高压和肝功能减退为特征,常并发上消化道出血、肝性脑病、继发感染等而死亡。门脉高压常导致食管胃底静脉曲张出血、腹水、脾肿大、脾功能亢进、肝肾综合征、肝肺综合征等,被认为是继病因之后的促进肝功能减退的重要病理生理环节,是肝硬化的主要死亡原因之一。     

Management before hepatectomy for hepatocellular carcinoma with cirrhosis

The global distribution of hepatocellular carcinoma (HCC) varies markedly among regions, and patients in East Asia and Central Africa account for about 80% of all cases. The risk factors are hepatitis B, hepatitis C, alcohol, and etc. The risk of carcinogenesis further increases with progression to hepatic cirrhosis in all liver disorders. Radical treatment of HCC by liver resection without causing liver failure has been established as a safe approach through selection of an appropriate range of resection of the damaged liver. This background indicates that both evaluation of hepatic functional reserve and measures against concomitant diseases such as thrombocytopenia accompanying portal hypertension, prevention of rupture of esophageal varices, reliable control of ascites, and improvement of hypoalbuminemia are important issues in liver resection in patients with hepatic cirrhosis. We review the latest information on perioperative management of liver resection in HCC patients with hepatic cirrhosis.     

肝硬化的胃肠道并发症

肝硬化是慢性肝病的终末阶段,可影响到全身多器官功能。而肝硬化所致消化道损害临床上更为常见。肝硬化会导致胃肠动力下降、影响营养物质的消化吸收及破坏肠黏膜屏障功能,还会并发一系列胃肠道并发症,影响患者预后。临床上,更应重视肝硬化相关胃肠道并发症,做到早期监测、早期诊断和早期治疗,控制肝硬化病情进展、减少晚期并发症、提升患者生活质量。     

乙型肝炎肝硬化门脉高压症行脾切除联合门奇静脉断流术后影响预后的因素分析

目的分析影响乙型肝炎肝硬化门脉高压症行脾切除联合门奇静脉断流术后预后的主要因素。方法2014年6月~2015年6月我科行脾切除联合门奇静脉断流术治疗的乙型肝炎肝硬化门脉高压症患者74例,采用Cox回归分析影响术后预后的因素。结果术后随访3年,生存患者60例（81.1%）,死亡患者14例（18.9%）;单因素分析结果显示,死亡患者年龄≥50岁、合并疾病基础、CTP评分>10分、术前存在食管静脉曲张史、术中出血量>600 mL、术中输血量>500 ml、急诊手术、术后发生并发症、术后肝炎活动、治疗依从性差等显著高于生存患者（P<0.05）;多因素分析结果显示,患者术后发生并发症、合并基础疾病、肝硬化分级差、术后肝炎活动和患者对治疗依从性差等均为影响患者术后预后的危险因素（P<0.05）。结论影响乙型肝炎肝硬化门脉高压症患者术后预后的因素较多,应针对性地做好防治工作,提高患者生存率。     

Attenuation of portal hypertension by natural taurine in rats with liver cirrhosis

AIM： To investigate the inhibitory effect of natural taurine （NTau） on portal hypertension （PHT） in rats with experimentally-induced liver cirrhosis （LC）. METHODS： Experimentally-induced LC Wistar rats （20 rats/group） were treated with either oral saline or oral NTau for 6 consecutive weeks. Evaluation parameters included portal venous pressure （PVP）, portal venous resistance （PVR）, portal venous flow （PVF）, splanchnic vascular resistance （SVR） and mean arterial pressure （NAP）. Vasoactive substance levels including nitric oxide （NO）, nitric oxide synthase （NOS） and cyclic guanosine monophosphate （cGMP） were also measured. Histological investigation of type Ⅰ and Ⅲ collagen （COL Ⅰ and Ⅲ） and transforming growth factor-β1 （TGF-β1） was also performed. RESULTS： Treatment with NTau （1） significantly decreased PVP, PVR and PVF, and increased MAP and SVP; （2） markedly increased the vascular compliance and reduced the zero-stress of the portal vein; （3） markedly decreased the amount of NO and cGMP and activity of NOS; and （4） improved the pathological status of the liver tissue and reduced the expression of COL Ⅰ, COL Ⅲ and TGF-β1. CONCLUSION： NTau inhibited the LC-induced PHT by improving hyperdynamic circulation, morphology of liver and biomechanical properties of the portal vein in experimentally-induced LC rats.     

Impact of surgical volume on nationwide hospital mortality after pancreaticoduodenectomy

AIM: To evaluate the impact of surgical volume on nationwide hospital mortality after pancreaticoduodenectomy (PD) for periampullary tumors in South Korea.METHODS: Periampullary cancer patients who underwent PD between 2005 and 2008 were analyzed from the database of the Health Insurance Review and Assessment Service of South Korea. A total of 126 hospitals were divided into 5 categories, each similar in terms of surgical volume for each category. We used hospital mortality as a quality indicator, which was defined as death during the hospital stay for PD, and calculated adjusted mortality through multivariate logistic models using several confounder variables.RESULTS: A total of eligible 4975 patients were enrolled in this study. Average annual surgical volume of hospitals was markedly varied, ranging from 215 PDs in the very-high-volume hospital to < 10 PDs in the very-low-volume hospitals. Admission route, type of medical security, and type of operation were significantly different by surgical volume. The overall hospital mortality was 2.1% and the observed hospital mortality by surgical volume showed statistical difference. Surgical volume, age, and type of operation were independent risk factors for hospital death, and adjusted hospital mortality showed a similar difference between hospitals with observed mortality. The result of the Hosmer-Lemeshow test was 5.76 (P = 0.674), indicating an acceptable appropriateness of our regression model.CONCLUSION: The higher-volume hospitals showed lower hospital mortality than the lower-volume hospitals after PD in South Korea, which were clarified through the nationwide database.     

肝硬化门静脉高压并发症对预后的影响

目的 了解门静脉高压各并发症在失代偿肝硬化患者的发生情况和各并发症对患者预后的影响.方法 选择失代偿期肝硬化患者的病历资料进行登记和随访,根据随访结果,分析患者门静脉高压并发症的发生情况;利用终末期肝病模型(MELD)公式,计算出MELD值并进行分级,同时计算Child-Turcotte-Pugh(CTP)分级,分别分析CTP分级和MELD分级中门静脉高压并发症发生情况和患者生存状况.利用Kaplan-Meier生存分析方法分析门静脉高压并发症对肝硬化患者生存率的影响.利用x2检验和时序性检验比较生存率差别,Cox比例风险回归分析各个并发症对患者生存影响作用的大小.结果 在符合条件的322例失代偿期肝硬化患者中,发生食管胃底静脉曲张破裂出血、肝性脑病、大量腹水、自发性腹膜炎、肝肾综合征Ⅰ型和Ⅱ型的患者病死率分别是45.9%、79.4%、66.7%、100%、100%和84.6%.各并发症的发生基本按CTP分级和MELD值的增加而逐渐升高.经过Kaplan-Meier生存分析,除少量和中量腹水外,各并发症对患者生存率的影响,P值均<0.01,差异均有统计学意义.由Cox回归过程分析出肝性脑病、自发性腹膜炎、肝肾综合征Ⅰ型和Ⅱ型,食管胃底静脉曲张破裂出血和腹水的回归系数分别为0.973、0.928、0.935、0.866、0.464和0.369. 结论 门静脉高压并发症均能对失代偿期肝硬化患者的预后造成明显影响,其中影响程度最大的是肝性脑病.     

Contemporary concepts of the medical therapy of portal hypertension under liver cirrhosis

Severe complications of liver cirrhosis are mostly related to portal hypertension. At the base of the pathogenesis of portal hypertension is the increase in hepatic vascular resistance to portal blood flow with subsequent development of hyperdynamic circulation, which, despite of the formation of collateral circulation, promotes progression of portal hypertension. An important role in its pathogenesis is played by the rearrangement of vascular bed and angiogenesis. As a result, strategic directions of the therapy of portal hypertension under liver cirrhosis include selectively decreasing hepatic vascular resistance with preserving or increasing portal blood flow, and correcting hyperdynamic circulation and pathological angiogenesis, while striving to reduce the hepatic venous pressure gradient to less than 12 mmHg or 20% of the baseline. Over the last years, substantial progress in understanding the pathophysiological mechanisms of hemodynamic disorders under liver cirrhosis has resulted in the development of new drugs for their correction. Although the majority of them have so far been investigated only in animal experiments, as well as at the molecular and cellular level, it might be expected that the introduction of the new methods in clinical practice will increase the efficacy of the conservative approach to the prophylaxis and treatment of portal hypertension complications. The purpose of the review is to describe the known methods of portal hypertension pharmacotherapy and discuss the drugs that may affect the basic pathogenetic mechanisms of its development.     

诱导型和内皮型一氧化氮合酶基因多态性与肝硬化门静脉高压的相关性

目的探讨诱导型一氧化氮合酶(iNOS)和内皮型一氧化氮合酶(eNOS)基因多态性与肝硬化门静脉高压的相关性。方法采用病例对照和聚合酶链反应-限制性片段长度多态性技术,检测106 例乙型肝炎后肝硬化患者(其中门静脉高压症65例)和108名健康对照者iNOS基因启动子-969G→C多态性及eNOS基因第七外显子894G→多态性,比较等位基因及基因型频率,并进行综合分析。结果在iNOS启动子969G→C多态性中,门静脉高压症组C等位基因和GC基因型频率比对照组显著升高(x2- 5.93,P<0.05)。GC基因型启动子的活性比GG基因型活性强。在eNOS的894G→T多态性中,T等位基因频率明显高于对照组(x2-3.91,P<0.05)。采用Logistic多元回归显示iNOS基因启动子-969G→C多态性及cNOS的894G→T多态性是门静脉高压症新的危险因素。结论iNOS启动子969G→C多态性和eNOS的894G→T多态性与门静脉高压症相关,是形成门静脉高压症新的危险因素。iNOS启动子-969G→C多态性可导致该基因启动子功能活性增强。     

Association of liver cirrhosis related IgA nephropathy with portal hypertension

A high incidence of IgA nephropathy has been reported in patients with liver cirrhosis, though, clinically evident nephrotic syndrome is very uncommon. Impaired hepatic clearance of circulating IgA immune complexes and subsequent deposition in renal glomeruli has been considered principally in the pathogenesis of liver cirrhosis associated IgA nephropathy. Here we report on a patient with cryptogenic liver cirrhosis and splenic vein thrombosis, who presented with nephrotic syndrome. Renal biopsy showed findings consistent with IgA nephropathy. Lower endoscopy showed features of portal hypertensive colopathy. Following initiation of propranolol and anticoagulant treatment to reduce portal pressure, a gradual decrease of proteinuria and hematuria to normal range was noted. The potential pathogenetic role of portal hypertension in the development of IgA nephropathy in cirrhotic patients is discussed.     

Body composition changes after transjugular intrahepatic portosystemic shunt in patients with cirrhosis

AIM:To investigate the effect of transjugular intra-hepatic porto-systemic shunt (TIPS) on malnutrition in portal hypertensive cirrhotic patients.METHODS: Twenty-one patients with liver cirrhosis and clinical indications for TIPS insertion were investigated before and 1, 4, 12, 52 wk after TIPS. For each patient we assayed body composition parameters [dry lean mass, fat mass, total body water (TBW)], routine liver and kidney function tests, and free fatty acids (FFA). Glucose and insulin were measured for t...     

Spontaneous bacterial peritonitis： A severe complication of liver cirrhosis

This report presents a survey of current knowledge concerning one of the relatively frequent and severe complications of liver cirrhosis and associated ascitesspontaneous bacterial peritonitis. Epidemiology,aetiology, pathogenesis, clinical manifestation, diagnosis and present possibilities of treatment are discussed.     

Systemic hemodynamics in advanced cirrhosis: Concerns during perioperative period of liver transplantation

Advanced liver cirrhosis is usually accompanied by portal hypertension. Long-term portal hypertension results in various vascular alterations. The systemic hemodynamic state in patients with cirrhosis is termed a hyperdynamic state. This peculiar hemodynamic state is characterized by an expanded blood volume, high cardiac output, and low total peripheral resistance. Vascular alterations do not disappear even long after liver transplantation(LT), and recipients with cirrhosis exhibit a persistent systemic hyperdynamic state even after LT. Stability of optimal systemic hemodynamics is indispensable for adequate portal venous flow(PVF) and successful LT, and reliable parameters for optimal systemic hemodynamics and adequate PVF are required. Even a subtle disorder in systemic hemodynamics is precisely indicated by the balance between cardiac output and blood volume. The indocyanine green(ICG) kinetics reflect the patient's functional hepatocytes and effective PVF, and PVF is a major determinant of the ICG elimination constant(kICG) in the well-preserved allograft. The kICG value is useful to set the optimal PVF during living-donor LT and to evaluate adequate PVF after LT. Perioperative management has a large influence on the postoperative course and outcome; therefore, key points and unexpected pitfalls for intensive management are herein summarized. Transplant physicians should fully understand the peculiar systemic hemodynamic behavior in LT recipients with cirrhosis and recognize the critical importance of PVF after LT.     

肝硬化门静脉高压症患者断流术后转归的影响因素分析

目的:研究肝硬化门静脉高压症患者断流术后转归的影响因素．方法:回顾性分析行断流术的肝硬化门静脉高压症患者158例．根据术后并发症情况将患者分为高危组和一般组2组．将其作为因变量,将23个临床指标作为自变量,进行Logistic回归分析．结果:影单因素分析显示,高危组和一般组凝血酶原时间(PT,P=0．007)、Child分级(P= 0．001)、术中所见肝硬化程度(P=0．002)、B型超声测得盆腔腹水前后径值(P=0．023)、胃镜所见食道胃底静脉曲张程度(P=0．010)有显著性差异．Logistic回归分析显示,Child分级、PT和术中所见肝脏硬化程度在两组间仍有显著差异．结论:肝硬化门静脉高压症患者断流术后转归的影响因素为Child分级、PT和术中所见肝脏硬化程度．     

肝硬化食管胃静脉曲张破裂出血的相关危险因素分析

目的探讨可以评估肝硬化患者食管胃静脉曲张破裂出血风险的临床指标。方法回顾性分析572例合并食管胃静脉曲张破裂出血的肝硬化患者(观察组)及704例未发生出血的肝硬化患者(对照组)的临床资料,对两组间存在差异性的指标运用单因素和多因素Logistic回归模型进行分析。结果两组在肝功能分级状况(P0.05)、血清白蛋白(t=5.05,P=0.000)、凝血酶原时间(t=-2.80,P=0.005)、门静脉内径(t=-2.28,P=0.006)、脾脏厚度(t=-2.73,P=0.006)方面比较,差异有统计学意义。单因素非条件Logistic回归分析显示白蛋白(OR=0.944,P=0.000)、凝血酶原时间(OR=1.067,P=0.007)、门静脉内径(OR=3.423,P=0.007)、脾脏厚度(OR=1.276,P=0.007)与出血存在相关性,进一步多因素非条件Logistic回归分析提示白蛋白(OR=0.936,P=0.000)、门静脉内径(OR=4.098,P=0.013)、脾脏厚度(OR=1.275,P=0.007)是出血的独立危险因素。结论白蛋白、门静脉内径、脾脏厚度是肝硬化并发食管胃静脉曲张破裂出血的独立危险因素,对预测食管胃静脉曲张破裂出血的发生有重要的临床价值,改善白蛋白可在一定程度上减少肝硬化并发食管胃静脉曲张破裂出血的风险。     

Laparoscopic splenectomy for hypersplenism secondary to liver cirrhosis and portal hypertension

Since the first laparoscopic splenectomy(LS)was reported in 1991,LS has become the gold standard for the removal of normal to moderately enlarged spleens in benign conditions.Compared with open splenectomy,fewer postsurgical complications and better postoperative recovery have been observed,but LS is contraindicated for hypersplenism secondary to liver cirrhosis in many institutions owing to technical difficulties associated with splenomegaly,well-developed collateral circulation,and increased risk of bleeding.With the improvements of laparoscopic technique,the concept is changing.This article aims to give an overview of the latest development in laparoscopic splenectomy for hypersplenism secondary to liver cirrhosis and portal hypertension.Despite a lack of randomized controlled trial,the publications obtained have shown that with meticulous surgical techniques and advanced instruments,LS is a technically feasible,safe,and effective procedure for hypersplenism secondary to cirrhosis and portal hypertension and contributes to decreased blood loss,shorter hospital stay,and less impairment of liver function.It is recommended that the dilated short gastric vessels and other enlarged collateral circulation surrounding the spleen be divided with the LigaSure vessel sealing equipment,and the splenic artery and vein be transected en bloc with the application of the endovascular stapler.To support the clinical evidence,further randomized controlled trials about this topic are necessary.