肝硬化门静脉高压症脾保留术的研究进展

脾切除加断流和（或）分流术是治疗肝硬化门静脉高压症主要的手术方法，其重要性在于既能纠正脾功能亢进（脾亢）状态，又能有效地降低门静脉压力，从而达到止血目的。随着病理脾保留术（保脾术）的兴起，学者们尝试对肝硬化门静脉高压症行各种保脾术，并取得了一定的效果，现结合相关文献，对其研究进展综述如下。     

脾切除对病毒性肝炎肝硬化合并门静脉高压症患者肝癌发生影响的多中心队列研究

目的:探讨脾切除术对肝硬化合并门静脉高压症患者发生肝细胞癌（HCC）的影响。方法:回顾性收集2008年1月至2012年12月中国7所三级医院收治的因肝硬化和门静脉高压症继发脾功能亢进行脾切除术的407例患者的病例资料,纳入脾切除组;将同期因肝硬化和门静脉高压症接受药物治疗的464例患者的病例资料纳入非脾切除组。脾切除术...     

脾大部切除术治疗门静脉高压症的应用与评估

近１０余年来,国内多家医院已开展了在门静脉高压症治疗时施行脾大部分切除术［１～５］。从大量的实验和临床研究表明门静脉高压症病人的整个免疫功能均有所低下,但作为机体最大的外周淋巴器官之脾脏,仍对病人的体液和细胞免疫有重要的调控作用,且具有强大的抗感染等免疫功能,同时术中将残脾置于腹膜后,借此形成广泛的侧支,起到建立脾肾分流的“桥梁”作用。１　门静脉高压症行脾大部切除术中的几个问题１－１　门静脉高压症脾大部切除的原则　　我们认为门静脉高压症行脾大部切除应遵循以下原则：（１）结扎脾动脉主干,以切断残脾…     

完全腹腔镜下脾切除联合贲门周围血管离断术的临床应用

目的 探讨完全腹腔镜下脾切除联合贲门周围血管离断术的适应证和临床应用价值.方法 分析对40例肝硬化门静脉高压症脾亢患者采用完全腹腔镜下脾切除联合贲门周围血管离断术的临床资料.结果 本组中36例顺利完成完全腹腔镜下脾切除联合贲门周围血管离断术,4例中转开腹,平均手术时间(224±54)min,平均术中出血量(296±209)ml,无严重并发症.结论 对门静脉高压脾亢患者选择性地采用完全腹腔镜下脾切除联合贲门周围血管离断术是一种可供选择的安全、有效的微创方法.     

远端脾肾分流术联合脾部分切除治疗门静脉高压症脾功能亢进疗效探讨

目的 对比研究远端脾肾分流术（Warren术）与远端脾肾分流术联合脾部分切除治疗门静脉高压症脾功能亢进的疗效。方法 选取第四军医大学唐都医院2010年以来22例获得完整随访资料的行外科手术治疗的门静脉高压症脾功能亢进病人,其中Warren术组（分流组）8例,Warren术+脾部分切除组（分流+切脾组）14例,比较观察两组术前、术后第7、30天的外周血象主要指标（白细胞、血小板）以及两组术前、术后第30天外周血免疫指标（IgG、 IgA 、IgM）。结果 Warren术+脾部分切除组病人术后白细胞及血小板恢复指标明显优于Warren术组,差异有统计学意义（P<0.05）;外周血免疫球蛋白检测显示两组术后与术前比较差异无统计学意义（P>0.05）。结论 Warren术联合脾部分切除治疗门静脉高压症脾功能亢进疗效优于单纯Warren术。在有效降低门静脉压力前提下很大程度上解决脾功能亢进,又保留了脾脏正常免疫功能。但切除脾脏比例以及适应证等需根据病人制定个体化治疗方案,尤其在切除脾脏比例方面需要进一步研究验证。     

门静脉高压症时脾动脉盗血对脾功能亢进的影响

<正>肝硬化门静脉高压症患者血流动力学出现明显异常,脾脏增大、脾亢、脾静脉增粗、血流量增加,门静脉增宽,侧枝循环扩张等,可能为机体代偿所致,但脾动脉血流动力学研究较少。本研究旨在探讨肝硬化门静脉高压症时是否存在脾动脉盗血及可能引起脾亢的发生机制,现报告如下。     

门静脉高压症断流术中脾动脉结扎和脾切除的临床疗效比较

目的 探讨腹腔镜脾动脉结扎联合贲门周围血管离断术治疗门静脉高压症的可行性与有效性.方法 回顾性分析2014年1月至2019年12月河北医科大学第二医院手术治疗的80例肝硬化门静脉高压症患者的临床资料,其中50例行腹腔镜脾动脉结扎联合贲门周围血管离断术,30例行腹腔镜脾切除联合贲门周围血管离断术.结果 与脾切除组相比,脾...     

门静脉高压症脾功能亢进脾巨噬细胞吞噬功能的变化及其与脾亢程度的相关性

目的　观察门静脉高压症患者脾功能亢进(脾亢)时,脾脏巨噬细胞(MΦ)吞噬功能及其与外周血细胞计数变化的相关性。方法　肝硬化门静脉高压症脾亢患者20例(脾亢组),外伤性脾破裂患者6例(对照组)。术前检测患者外周血细胞计数,并收集其手术切除的脾脏,用玻片贴壁法分离培养脾脏MΦ,鸡红细胞吞噬法检测MΦ的吞噬功能。结果　脾脏MΦ吞噬率:脾亢组为(12 6±3 0)%,显著高于对照组(6 9±0 5)%,P<0 01;吞噬指数:脾亢组为0 146±0 035,显著高于对照组0 076±0 008,P<0 01。外周血白细胞计数与脾MΦ的吞噬率负相关(r=-0 472,P<0 05),与吞噬指数也呈负相关(r=-0 625,P<0 01);外周血血小板计数与脾MΦ吞噬率负相关(r=-0 485,P<0 05),与吞噬指数负相关(r=-0 523,P<0 05)。结论　门静脉高压症脾亢脾MΦ吞噬功能增强可能是引起脾亢发生及决定脾亢程度的重要因素。     

门静脉高压症患者行脾切除术对肝癌发生及复发影响的研究进展

目的探讨门静脉高压症患者行脾切除对肝癌发生及复发的影响。方法复习近年来国内外关于肝硬变合并门静脉高压症患者及肝癌合并门静脉高压症患者行脾切除术的研究文献,并进行综述。结果目前大部分学者认为,对肝硬变合并门静脉高压症患者行脾切除术可以降低肝癌的发生率,而对肝癌合并门静脉高压症患者同期行肝脾联合切除手术不增加围手术期死亡率,并能降低肝癌的复发率。结论门静脉高压症患者行脾切除是安全可行的,脾切除能抑制肝癌的发生及进展,但具体机制仍待进一步研究。     

脾切除保留副脾十例的临床观察

我院从 1992年以来对肝硬变门静脉高压症和脾外伤者行脾切除时保留副脾 12例 ,对其中随访资料完整的 10例的副脾形态变化及免疫功能进行观察 ,报告如下。临床资料1.一般资料 :本组共 10例 ,男 7例 ,女 3例 ,年龄 11～ 5 4岁 ,平均年龄 2 8岁 ,肝硬变门静脉高压症 6例 ,脾外伤 4例(其中 2例同时行脾片移植 )。副脾位于脾门处 6例 ,胰尾上缘处 2例 ,胰尾下缘处 1例 ,脾结肠韧带处 1例。随访时间2年 6个月至 11年。对照组 30例均为肝硬变门静脉高压症脾切除患者 ,年龄 2 1～ 5 6岁 ,平均 39 3岁。2 .检测项目 :影像学检查以B超为主 ,必要时做C…     

Contraindications to splenectomy in primary total extrahepatic portal hypertension

The authors studied changes of hepatic circulation, hepatoportal hemodynamics, and homeostasis of peripheral and portal venous blood in response to removal of the spleen in primary total extrahepatic portal hypertension. The findings of rheohepatography, isotope hepatography, and ultrasonic flow measurement provided proof that splenectomy does not lead to intensification of the flow of arterial blood to the liver. Study of the portal pressure level did not demonstrate any significant hypotensive effect of splenectomy. Considerable changes occur after removal of the spleen, which creates real preconditions for the development of portal system thrombosis. All the above-said provides the basis for reducing considerably the range of indications for splenectomy and recommending it only in cases with marked clinical manifestations of hypersplenism hemolysis and increased tendency to bleeding.     

The significance of sinistral portal hypertension complicating chronic pancreatitis

BACKGROUND: Sinistral portal hypertension, a localized (left-sided) form of portal hypertension may complicate chronic pancreatitis as a result of splenic vein thrombosis/obstruction. AIM:To determine appropriate surgical strategy for patients with splenic vein thrombosis/obstruction secondary to chronic pancreatitis. METHODS: We reviewed our experience with operative management of 484 consecutive patients with histologically documented chronic pancreatitis treated between 1976 and 1997. The diagnosis of sinistral portal hypertension was based on clinical presentation, preoperative endoscopic and radiographic imaging, and operative findings. "Symptomatic," herein defined, denotes those patients with sinistral hypertension and either gastrointestinal bleeding or hypersplenism. "Asymptomatic" patients were those with sinistral hypertension alone. RESULTS: Sinistral portal hypertension was present in 34 of the 484 patients (7%). Gastric or gastroesophageal varices were confirmed in 12 patients (35%), of whom 6 had variceal bleeding and 4 had hypersplenism (25%). All symptomatic patients were treated by splenectomy alone or in conjunction with distal pancreatectomy. Splenectomy at the time of pancreatectomy for primary pancreatic symptoms was also performed in 15 patients with (asymptomatic) sinistral portal hypertension. None of the 23 patients who had splenectomy rebled in mean follow-up of 4.8 years. In contrast, 1 of the 11 patients with asymptomatic sinistral portal hypertension who underwent pancreatic surgery without splenectomy died of later variceal bleeding 3 years after lateral pancreatojejunostomy. CONCLUSIONS: Symptomatic sinistral portal hypertension is best treated by splenectomy. Concomitant splenectomy should be strongly considered in patients undergoing operative treatment of symptomatic chronic pancreatitis if sinistral portal hypertension and gastroesophageal varices are also present.     

肝炎肝硬化病人脾切除术后门静脉血栓形成的相关因素分析

目的 分析肝炎肝硬化门静脉高压症病人脾切除术后门静脉系统血栓形成的相关因素.方法 我院2000年8月至2007年6月共为226例肝炎肝硬化门静脉高压症病人施行了脾切除或脾切除加断流术.本文对其中154例进行回顾性分析.根据是否形成血栓将病例分为门静脉系统血栓形成和无血栓形成两组.用Logistic回归分析术前术后门静脉压力下降水平、术前凝血酶原比值(PTR)、术前纤维蛋白原水平(FIB)、术前及术后1、7、14 d血小板水平、术前门静脉直径、术前胆红素水平、术中出血量各指标与门静脉系统血栓形成的关系.结果 在154例病人中,门静脉系统血栓形成31例,123例无血栓形成.Logistic单因素分析和多因素回归分析均显示门静脉系统血栓形成与门静脉压力下降水平有关;术前凝血酶原比值(PTR)、术前纤维蛋白原水平(FIB)、术前及术后1、7、14 d血小板水平、术前门静脉直径、术前胆红素、术中出血量水平与门静脉血栓形成无关.结论 术前、术后门静脉压力下降水平可能是影响门脉高压脾切除术后门脉系统血栓形成的重要因素,术后门静脉压力下降越多,门静脉系统血栓形成几率越高.     

门静脉高压症保脾的有关问题

脾脏是人体最大的外周免疫器官，在机体免疫反应中发挥了重要作用。但对于门静脉高压症是否保脾一直存有争议，核心在于此种情况下的病理脾是否仍具有正常脾脏的免疫功能，保留后对机体是“利”还是“弊”。本文以脾脏的免疫功能为基础，阐述了门静脉高压症施行保脾手术的根据、历史沿革以及面临的问题。提出在深化脾脏功能的基础研究、统一标准和遵循“个体化”原则的基础上，以辩证的思维探讨门静脉高压症保脾的合理性、必要性和重要性，从而为门静脉高压症选择合理的手术方式提供理论依据。     

Spleno-renal distal and proximal shunts for hypersplenism due to hepatic cirrhosis

The secondary hypersplenism appears from 30-50% in liver cirrhosis with portal hypertension. The mechanism of the complication is the splenic congestion as the result of the progress of the portal hypertension. Between 1997-2005, 16 patients with hypersplenism due to liver cirrhosis were operated in the service. The aim of the operation was to decompress the portal hypertension, by spleno-renal shunt (Warren), in 6 patients, truncular shunts in 2 patients, and splenectomy with spleno-renal shunts in 8 patients. No postoperative death was noted on the series. The platelets number and the white blood cells, destroyed by the reticuloendothelial system of the spleen, were counted in the first month and the first year, as well as the spleen volume. In patients with non-splenectomy operations the improvement of the blood elements number was remarked in the first week, but the volume of the spleen remained increased during 1-6 month. In patients with splenectomy the platelets and the white cells dramatically increased, with the risk of coagulation disfunction. The survival rate at five years was 12 patients.     

Idiopathic portal hypertension in renal transplant recipients: Report of two cases

We present herein the cases of two patients who developed idiopathic portal hypertension (IPH) following renal transplantation. Both patients had been treated with azathioprine and prednisolone for 6 years and 4 months and for 4 years and 7 months, respectively, and presented with splenomegaly and thrombocytopenia suggesting hypersplenism. Celiac angiography showed a dilated splenic artery and vein in both patients. When the splenic artery was obliterated with a balloon catheter in case 1, the portal venous pressure decreased from 51 cmH₂O to 36 cmH₂O and the direction of the superiomesenteric venous blood flow became hepatopetal rather than hepatofugal. These results suggested that the spleen might have played an important role in the development of IPH in these two patients. A splenectomy was therefore performed, immediately following which the portal venous pressure decreased remarkably, and the esophageal varices disappeared during the postoperative follow-up period. Microscopic examination of liver biopsies taken at the operation revealed lymphoplasmacytic infiltration with bile duct hyperplasia but no evidence of periportal fibrosis, and electron microscopy demonstrated very mild perisinusoidal fibrosis. Thus, the histological changes seen in the livers of these patients seemed not to have caused the portal hypertension. In conclusion, although few patients develop IPH after renal transplantation, we should be aware of its possibility and consider splenectomy as the treatment of choice.     

Surgical treatment of schistosomal portal hypertension

Schistosomiasis mansoni is a widespread parasitic disease in the Brazilian territory that affects over 8 million individuals. Hepatosplenic schistosomiasis is a serious clinical presentation of this disease, associated with splenomegaly, liver fibrosis, and portal hypertension, and is responsible for approximately 7% of schistosomotic patients. The surgical treatment of portal hypertension in schistosomotic patients has distinct features when compared with cirrhotic patients, mostly because hepatic function is preserved in schistosomotic liver disease. Therefore, when attempting to reduce the portal pressure, the surgeon must be aware that the surgery might interfere with hepatic perfusion, and consequently with hepatic function. The aim of this study was to report the results achieved with splenectomy, division of the left gastric vein, devascularization of great gastric curvature, and postoperative endoscopic variceal sclerosis, as a surgical option to esophageal varices in hepatosplenic schistosomiasis. A total of 111 patients were studied, and the following is a list of inclusion criteria: age >16 years, history of gastrointestinal (GI) bleeding, presence of esophageal varices on preoperative endoscopy, hematocrit >22% and prothrombin enzymatic activity >50%, negative viral hepatitis on serologic tests (anti-HBV and anti-HCV), and definition, after liver biopsy, of exclusive schistosomotic liver disease. The following list includes exclusion criteria used: presence of liver disease other than schistosomotic, history of alcohol abuse, and preoperative thrombosis of the portal vein. The rebleeding rate was 14.4% during a mean 30-month follow-up period; portal vein thrombosis was 13.2%, and there was a global mortality of 5.4%. Gastric varices were present in 46.9% of the patients; for those patients, a gastrotomy and running suture of the varices achieved an eradication rate of the varices of 75.6%. The degree of periportal fibrosis was also analyzed. Periportal fibrosis staging revealed that patients with class II or III liver fibrosis had a significant increased risk of recurrent GI bleeding when compared with patients with class I liver fibrosis. Despite the elevation on alanine aminotransferase (ALT) and aspartate aminotransferase (AST), most other liver function tests showed no alteration or were corrected after surgery. We conclude that splenectomy, division of the left gastric vein, devascularization of great gastric curvature, and postoperative endoscopic variceal sclerosis showed good results globally and should be considered as therapeutic options in the treatment of hepatosplenic schistosomiasis.     

细胞间粘附因子-1在门静脉高压患者脾静脉的表达及意义

目的 探讨细胞间粘附因子—1(ICAM—1)在门静脉高压患者脾静脉的表达及其在贲门周围血管离断术后门静脉血栓形成的意义。方法 对34例门静脉高压患者和34例单纯脾破裂患者的脾静脉行苏木素—伊红染色观察形态学变化；行ICAM—1原位杂交并行定量分析，术后观察门静脉血栓的发生，对两者的关系进行研究。结果 门静脉高压患者脾静脉中膜平滑肌增生，内膜增厚，门静脉高压组和脾破裂组之间脾静脉内皮细胞ICAM—1mRNA表达差异有非常显著性(P＜0．01)；脾破裂组术后无门静脉血栓形成，门静脉高压组有8例门静脉血栓形成；门静脉高压组内有无门静脉血栓形成病例之间脾静脉内皮细胞ICAM—1mRNA表达差异有显著性(P＜0．05)。结论 门静脉高压性血管病变及其内皮细胞ICAM—1mRNA过度表达可能是门静脉高压患者门静脉血栓形成重要原因。     

肝硬化门静脉高压脾切断流术后影响门静脉系统血栓形成的因素

目的：探讨脾切断流术后门静脉血栓形成（PVT）的危险因素及防治方法。方法：回顾性分析12年间1 300例行脾切除+贲门周围血管离断术治疗肝硬化门静脉高压患者的临床资料,观察其术后PVT形成情况,并对术后PVT形成的因素进行分析。结果：全组术后PVT发生率为30.15%（392/1 300）;PVT形成与患者年龄、合并糖尿病、食管胃底静脉曲张程度、肝功能分级、D-二聚体、脾脏大小、是否抗凝治疗等因素有关（均P<0.05）,而与患者性别、手术时间和术中出血量无关（均P>0.05）。结论：年龄、肝脏功能、门静脉压力、食管胃底静脉曲张、合并糖尿病、巨脾等是脾切断流术后PVT形成的影响因素;应用抗凝治疗可降低术后PVT的发生率。     

特发性门静脉高压症的诊治现状

特发性门静脉高压症(IPH)非常罕见,其特点是有门静脉高压,但没有肝硬化,有门静脉小分支堵塞或狭窄,却没有肝静脉和门静脉主干的堵塞。该疾病尚有其它命名,如:特发性非硬化性门静脉高压症、非肝硬化性门静脉纤维化等。IPH病因及发病机制未明确,可能与遗传、免疫、感染等因素相关。临床表现上IPH以脾功能亢进、胃食管静脉曲张为主,而少有肝功能不全、肝性脑病。诊疗上尚有不少争议,目前IPH的诊断为排除性诊断,治疗上多参考肝硬化性门静脉高压的指南。IPH预后资料不多,目前认为较肝硬化性门静脉高压者预后更佳,只有少数患者进展至肝衰竭。