门脉高压症患者门体分流术后血前列环素水平变化的临床观察

目的：初步探讨临床门脉高压症患者门体分流术后血前列环素水平的变化。方法：１５例（４５±１２岁）乙型肝炎后肝硬化（经病理证实）门脉高压症患者中，６例行门腔静脉人造血管搭桥分流术，９例行脾肾静脉分流术。于开腹后，探查前和术后４天分别抽取股动，静脉和胃网膜右静脉血各３ｍｌ，经处理后，取血浆标本保存、３周内用放免法测定其前列素含量。结果自身对照ｔ检验方法作统计学分析，结果：术后门静脉和周围静脉血中前列环素     

肝硬变门静脉高压症患者门体分流术前后血中内皮素、血栓素与前列环素动态临床观察

目的 了解肝硬变门静脉高压症患者、液递物质代谢紊乱及其血流动力学后果.方法 对30例肝硬变门静脉高压症患者门体分流术前后门脉血中内皮素(ET)、血栓素(TXA2)和前列环素(PGI2)进行了水平变化动态临床观察.结果 在门静脉高压症患者门脉血中无论是缩血管物质(ET、TXA2)还是扩血管物质(PGI2)浓度均比胃肠对照者明显升高(ERT:107.86±25.92 pg/ml,48.11±9.40pg/ml,P=0.000;TXA2:349.67±198.41pg/ml,156.27±54.01pg/ml,P=0.000;PGI2:463.14±108.25pg/ml,227.23±46.19 pg/ml,=0.000),且二者浓度在门体分流术后均下降(P=0.002).结论 门静脉血中内皮素水平的增高对肝硬变患者门脉血管阻力的增加有重要影响,并对门静脉高压症的发病机理起重要作用.在肝硬变门静脉高压这一特殊病理生理状态下,缩血管物质与扩血管物质之间可能达成一种新的动态平衡.     

肝硬变门脉高压症病人门体分流术后血浆前列环素含量变化的研究

用放射免疫分析方法观察了１５例肝炎后肝硬变门静脉高压症病人血中前列环素含量的变化。结果显示，门体分流术后，门静脉及周围静脉血中前列环素含量分别下降了４９．６３％（Ｐ＜０．０１）和２１．６４％（Ｐ＜０．０５）。门静脉血中前列环素含量的下降与门静脉压的下降呈正相关（ｒ＝０．７４，Ｐ＜０．０５）。表明肝硬变病人体内前列环素含量的增加主要是由于内脏血管内皮细胞合成增加所致，前列环素对门静脉高压症的形成以及维持其高压状态持续存在起一定作用。     

门—肺分流术治疗门脉高压症

自1985年11月至1992年3月,我们采用脾大部切除肺包脾大网膜包肺(门—肺分流)术(下称新术式)治疗肝肝硬化门脉高压症,包括兼做附加手术在内共计125例病人,其中单纯用新术式治疗计85例。并进行远期疗效观     

肝硬变门脉高压病人门体分流术后血浆前列环素含量变化的研究

用放射免疫分析方法观察了１５例肝炎后肝硬变门静脉高压症病人血中前列环素含量的变化，结果显示，门体分流术后，站静脉及周围静脉血中前列腺环含量分别下降了４９．６３％和２１．６４％。门静脉血中前旬环素含量的下降与门静压的下降呈正相关。表明肝变病人体内前环环素含量的增加主要是由于内脏血管内皮细胞合成增中所致，前列环素对门静脉高压症的形成以及维持其高压状态持续存在真情 定作用。     

门脉高压鼠血浆前列环素过多产生机制的实验研究

探讨门脉压力升高和门体分流在前列环素(PGI_2)升高中的作用。方法:36只雄性SD大鼠随机分为4组:肝前型(PHPH,n=8)和肝内型门脉高压(IHPH,n=9)、端侧门腔分流(PCS,n=8)以及手术对照组(SO,n=11)。模型制备后两周:(1)测游离门脉压(FPP);(2)应用同位素微球技术研究全身及内脏血流动力学;(3)从股动脉采集血样,用放射免疫法测血浆6-酮-前列腺素F_1α(6-keto-PGF_1α)浓度。结果:心脏指数(CI)和内脏血流量(PVI)是PCS>PHPH>IHPH>SO鼠。门体分流率(PSS)是PCS>PHPH>IHPH。在PHPH、IHPH、PCS和SO鼠,血浆6-keto-PGF_1α的浓度(ng/ml)分别为6.93±2.43、5.09±2.27、2.36±1.01和1.56±0.61,前3组鼠均显著高于SO鼠(P<0.05),且PHPH鼠和IHPH鼠均显著高于PCS鼠(P<0.05)。血浆6-keto-PGF1_1α浓度与FPP值呈非常显著性正相关(r=0.67,P<0.001)。结论:在门脉高压中,PGI_2升高主要是门脉压力升高刺激其在血管内皮细胞的合成增加,而门体分流和肝功能减退起次要作用。此外,本研究结果并不支持PGI_2参与门脉高压高血流动力学的发生。     

联合应用断流术和肠腔分流术治疗门脉高压症

作者联合应用贲门周围血管离断术与肠系膜上一下腔静脉侧侧分流术治疗肝硬变门脉高压症35例。术中对食管胃底静脉浆肌层缝扎术。肠系膜上静脉与下腔静脉采用3点固定连续郎贝尔缝合法侧侧吻合，口径限制在1．0～1．2cm。手术完成后自由门静脉压（FPP）为2．89士0．58kPa，较术前FPP（3．91士0．64kPa）降低有显著性差异（P＜0．01），但仍维持较高水平，保持向肝血流。术后肝功能均有不同程度的好转，腹水逐渐消失，食管静脉曲张消失明显，好转率为82．9％，肝性脑病发生率低（2．9％），无再出血发生，是目前治疗门脉高压症效果优良的可行性手术。     

门体分流术

门体分流术是将高压血流的门静脉或其主要属支与低压的下腔静脉或其主要属支直接吻合的一类手术的总称，一直是治疗或预防门静脉高压症食管曲张静脉破裂出血的主要手术方式，也是外科历史上开展最早、术式最多、迄今仍在争论与难以定型的一类手术[1]。传统的门体分流术，例如门腔、肠腔、脾肾、脾腔等端侧或侧侧吻合，均系完全性门体分流。其难以克服的缺点为术后入肝的血流量锐减而导致肝功能进行性减退及有一定的脑病发生率。为克服这些缺点，前辈们曾作过门静脉残端动脉化、控制分流口径等种什努力，但均因种种技术难题而未能解决，致使…     

断流术联合分流术治疗门脉高压症

食管静脉曲张破裂出血是门静脉高压症病人致命的并发症 ,其手术治疗时究竟是采用分流术还是断流术多年来一直颇有争议。既往多认为行断流术比较合理 ,但随着近年来对门静脉高压性胃病认识的逐渐加深 ,单纯行断流术的合理性受到责疑 ,提倡断流术联合分流术治疗门脉高压症的报道逐渐增多。我们自 1997年 1月～ 2 0 0 0年 12月间共行脾腔分流或脾肾分流加食管下段胃底周围血管离断术治疗门脉高压症 2 2例 ,取得了较为满意的近期效果 ,现报告如下 :临床资料一般资料 :本组病例中男 18例 ,女 4例 ,术后均经病理证实为肝炎后肝硬化 ,年龄 2 8～ 5 …     

Portosystemic shunt for the treatment of portal vein thrombosis following orthotopic liver transplantation

Abstract The efficacy of the portosystemic shunt operation for the treatment of portal vein thrombosis following orthotopic liver transplantation was demonstrated. From 1 July 1988 to 31 December 1991 42 portosystemic shunt operations were performed at our centre. In six of these cases portal vein thrombosis after orthotopic liver transplantation (OLT) was the indication for the procedure. All the patients retained adequate liver function but they demonstrated manifestations of significant portal hypertension, mainly variceal rebleeding. Two of the patients were children. Three patients underwent distal splenorenal shunt (DSRS), one mesocaval and one side-to-ide splenorenal shunt and the last one side-to-ide splenorenal shunt which was converted to DSRS 2 weeks later. All these patients were doing well after 30 months mean follow-up time without rebleeding or other signs of portal hypertension and none had so far required retransplantation.     

Ergebnisse mit dem distalen-splenorenalen Shunt nach Warren

Zusammenfassung In der Zeit vom 1. Mai 1977 bis 31. Dezember 1980 wurde bei 35 Patienten mit portaler Hypertension und gastro-oesophagealen Varicen ein Warren-Shunt angelegt. Es handelte sich um ein unselektioniertes Krankengut mit 9 Child A-, 21 Child B- und 5 Child C-Fällen. 5 Patienten (14,3 %) verstarben postoperativ — in einem einzigen Fall wegen eines technischen Fehlers, in drei Fällen im Coma hepaticum und in einem weiteren Fall an einem perforierten Magenulcus. Als postoperative Komplikation trat eine Rezidivblutung in sechs Fällen (17,1 %) auf. Zu einer postoperativen Pankreatitis kam es in keinem einzigen Fall. 15 Patienten wurden nach mindestens 6 Monaten nachuntersucht. Die Kontrollangiographie (inn = 15 = 100 %) ergab nur bei einem Patienten eine hepatofugale Strömung und eine Abnahme der Splenome galie in zehn Fällen. Nur bei einem einzigen Patienten traten Zeichen einer klinischen Encephalopathie auf. 14 Patienten konnten postoperativ ihre gewohnte Tätigkeit wieder aufnehmen. Die Spätthromboserate liegt mit 4,2 (in einem Fall) sehr niedrig, wobei die Umwandlungsmöglichkeit in einen portocavalen End-Seit-Shunt bestehen bleibt.

---

Results of the distal splenorenal warren shunt

Summary From May 1st 1977 until the end of December 1980 35 Warren shunts were performed upon unselected patients with portal hypertension and esophageal varices. According to the Child classification they were divided up into nine Child A, 21 Child B and five Child C cases. Five (14.3 %) postoperative deaths occurred, yet only one due to technical failure; three patients died of hepatic coma and one of a perforated gastric ulcer. As a postoperative complication recurrent bleeding occurred in six cases (17.1 %). Not even one case of pancreatitis could be observed. Fifteen patients were examined at least 6 months after operation. The control angiography (n = 15 = 100%) revealed hepatofugal circulation in only one case; splenomegaly was reduced in ten cases. Only one patient showed clinical signs of encephalopathy, fourteen patients were able to return to their normal activities. The late thrombosis rate was very low-only one case; however, the possibility of conversion to a portocaval shunt remains.

     

多排螺旋CT门静脉血管成像评价肝硬变门体分流的侧支血管

目的 介绍多排螺旋CT三维血管成像技术及其在评价肝硬变门体分流侧支循环方面的临床应用。方法 回顾性总结采用多排螺旋CT增强扫描，并通过最大密度投影、表面遮盖显示、容积再现等二维、三维重建技术来显示肝硬变门脉高压侧支循环血管的文献。结果 肝硬变门体分流侧支血管的分布、走行及解剖毗邻关系在多排螺旋CT门静脉血管成像图像上都能得到良好、直观的显示。结论 多排螺旋CT三维血管成像技术有利于血管走行的连续追踪和毗邻关系的清晰显示，有助于肝硬变门脉高压侧支循环的诊断。     

断流加分流联合术的门静脉血流动力学变化与临床疗效

目的：前瞻性分析门奇静脉断流加脾肾静脉分流术（联合手术）和断流术后的门静脉血流动力学变化与临床疗效。方 法：彩色多普勒超声监测各手术组门静脉系统血流动力学变化,随访临床疗效。结果：联合手术组ＰＶＤ术后平均下降０．２０ ｃｍ（１５．８７％）、ＰＶＦ平均下降２８８．２９ｍｌ／ｍｉｎ（４１．１５％）,ＦＰＰ平均Ｆ降０．６６ｋＰａ（１７.４１％）;断流组ＰＶＤ平均下降０．１３ｃｍ（９．２９％）, ＰＶＦ平均下降２００．７０ｍｌ／ｍｉｎ（３０．３５％）,ＦＰＰ平均下降０．３８ｋＰａ（１０．５６％）;联合手术组与断流组比较ＰＶＤ有明显差异（Ｐ＜ ０．０１）。再出血率分别为２.９％和１３．８％（Ｐ＜０.０５）,肝性脑病率分别为５．７％和３.５％（Ｐ＜０．０５）。结论：联合手术组的门静脉血 流动力学变化及临床疗效优于断流组。     

三种不同术式对门静脉血流动力学的观测

目的 :测定分流 (SRS)加断流手术 (PCDV)前后门静脉系统血流动力学变化 ,评价其在门静脉高压症外科治疗中的价值。方法 :应用彩色多普勒检测 99例门静脉高压症病人手术前后对门静脉系统的血流动力学的影响 ,术中动态测量门静脉压力。结果 :①SRS +PCDV组 :术后PVF减少 36 .1 0 %± 7.8% ,FPP下降 33 .99%± 9.53 %。FPP的下降与PVF的减少呈正相关 ,PVF和FPP较术前下降 (P <0 .0 5) ,但维持在正常高限且保持门静脉向肝血流 ;②SRS +PCDV组术后的PVF和FPP均介于断流组与脾肾分流组之间 ,且各组之间有显著差异 (P <0 .0 5)。结论 :分流手术后门静脉血流向肝内高灌注 ,门静脉系统瘀血状态依然存在。分流术后门静脉高压瘀血状态缓解 ;门静脉血流肝内灌注显著减少。分流术后门静脉压力降低 ,加做断流术后门静脉压力有不同程度回升 ,术后的PVF和FPP均介于断流术和分流术之间 ,该术式明显优于单纯分流术或断流术。     

‘Opening a can of worms’: Bilateral varicoceles as an indicator of underlying portal-hypertension

The scrotal varicocele is a common finding encountered during clinical examination. A porto-systemic shunt presenting with an associated varicocele is exceptionally rarely reported. Herein, we report such a case in an HIV positive man who presented with bilateral varicoceles. This is only the fifth case of such an association in the world literature. A literature review and the possible underlying pathophysiological mechanisms of this rare association are expanded further.     

Management of Major Portosystemic Shunting in Small-for-Size Adult Living-Related Donor Liver Transplantation with a Left-Sided Graft Liver

PURPOSE: We investigated the mechanisms of small-for-size graft syndrome by time-lag ligation, a novel approach to treating major portosystemic shunts in small-for-size adult living-related donor liver transplantation (LRDLT) using left-sided graft liver. METHODS: Five patients with end-stage liver failure and major splenorenal shunting underwent LRDLT using left lobe grafts. The average graft volume to recipient body weight (GV/RBW) ratio was 0.68 +/- 0.14. Two patients underwent time-lag ligation of their splenorenal (SR) shunts on postoperative days (PODs) 8 and 14, respectively. The shunts of the other three patients were untreated. RESULTS: The portal pressures in the first patient who underwent time-lag ligation rose above 300 mmH(2)O and remained there for 2 weeks. Thus, we ligated the SR shunt in the second patient on POD 14, resulting in an increase from 177 mmH(2)O to 258 mmH(2)O, but it decreased again thereafter. In the other three patients, the SR shunt was not ligated because portal blood flow volumes remained sufficient. Total bilirubin levels in the first time-lag ligation patient rose to 16 mg/dl, paralleling the rise in portal pressures. Although they increased after ligation in the second patient, they did not exceed 10 mg/dl. CONCLUSIONS: We recommend time-lag ligation if portal venous blood flow decreases in the early post-transplant period, but not until at least 2 weeks after transplantation. If the portal venous blood flow does not decrease, early postoperative ligation is unnecessary. If there are no major portosystemic shunts, making a portosystemic shunt might decompress excessive portal hypertension. With donor safety priority in LRDLT, novel approaches must be developed to enable the use of smaller donor grafts. We describe a potential means of using left lobe grafts in adult LRDLT.     

Current Role of Surgery in Portal Hypertension

Treatment for portal hypertension (PHT) has evolved from surgery being the only option during the 1970s to the wide range of options currently available. Surgery has not vanished from the therapeutic armamentarium, but its role has changed and is constantly evolving. The present review primarily focuses on the role of surgery in tackling patients with PHT and varices with regard to the Indian scenario and also looks at its relevance, given the availability of a host of other therapeutic options.     

���׸�Ӳ���ž�����ѹ֢θճĤ���ھ�����

目的　对肝炎肝硬化门静脉高压症病人胃粘膜的内镜表现进行分析研究 ,探讨以肝炎为病因的门静脉高压性胃病 (PHG)的内镜特征。方法　对 172例肝炎肝硬化门静脉高压症病人 (A组 )施行胃镜检查 ,详细记录镜下胃粘膜的病理表现及其分布 ,并与同期 114例尚未形成门静脉高压的肝炎肝硬化 (B组 )和 97例慢性胃炎 (C组 )进行对比。结果　A组主要的内镜表现包括马赛克征、糜烂、瘀点和樱桃红斑 ,检出率分别为 6 5 1%、5 0 0 %、4 5 3%和 19 8% ,均明显高于B、C两组 (P <0 0 1)。其中最基本的病变是马赛克征。樱桃红斑的检出率虽较低 ,但只在A组中见到。活动性出血的检出率A组亦高于B、C两组 (P <0 0 1)。B组与C组胃镜下的各种表现及其分布无显著性差异 (P >0 0 5 )。结论　马赛克征、糜烂和瘀点是肝炎肝硬化PHG的主要内镜表现 ,而樱桃红斑则是其特有的病变。肝炎肝硬化在形成门静脉高压以前 ,其胃粘膜的内镜表现与普通慢性胃炎相似。