免切割闭合器完全腹腔镜巨脾切除联合贲门周围血管离断术

目的探讨免切割闭合器完全腹腔镜巨脾切除联合贲门周围血管离断术治疗肝硬化门静脉高压症的手术技巧和临床应用价值。方法2005年3月～2006年10月,对23例肝硬化门静脉高压致食道下端静脉曲张患者行完全腹腔镜下巨脾切除联合贲门周围血管离断术治疗,其中18例免切割闭合器应用二级脾蒂离断法切除脾脏,即处理脾蒂时逐支分离脾叶动静脉,边分离边用血管夹夹闭或用丝线结扎后离断血管,并用超声刀离断小网膜后,逐一将贲门周围曲张静脉直接用超声刀或可吸收夹夹闭后离断,将脾脏放入标本袋,拉出扩大的trocar孔外,剪碎后取出。结果18例手术获得成功,手术时间180～320min,平均255min。术中出血量200～1600ml,平均450ml。术后发生胸腔积液2例,左膈下脓肿1例,B超引导穿刺治愈,轻度腹水2例。无死亡病例。术后住院时间6～17d,平均7.5d。18例术后随访5-24个月,平均16.4月,术后20个月再出血1例,经胃镜下注射硬化剂治愈,余17例均无再出血。结论应用二级脾蒂离断法处理脾蒂可以避免腹腔镜巨脾切除联合贲门周围血管离断术应用切割闭合器,不仅节省费用,而且在腹腔镜巨脾切除中有独特的优势。     

二级脾蒂离断法在腹腔镜巨脾切除联合贲门周围血管离断术中的应用

目的总结二级脾蒂离断法在完全腹腔镜下巨脾切除联合贲门周围血管离断术治疗肝硬化门静脉高压症的临床经验。方法2005年3月至2005年10月间,对15例肝硬化门静脉高压致食管下端静脉曲张患者行完全腹腔镜下巨脾切除联合贲门周围血管离断术治疗,其中13例应用二级脾蒂离断法处理脾蒂切除脾脏。结果13例在完全腹腔镜下成功应用二级脾蒂离断法巨脾切除联合贲门周围血管离断术,无1例中转开腹。手术时间(232±47)min,术中失血(480±232)ml。全组均于术后24-72 h内恢复胃肠蠕动,术后第1天下床活动,术后住院时间6-14 d,平均8．7 d。术后发生胸腔积液3例,左膈下脓肿1例,B超引导穿刺治愈。无死亡病例。结论在完全腹腔镜下巨脾切除联合贲门周围血管离断术中,应用二级脾蒂离断法不仅安全可行,而且节省费用,具有较大的临床推广价值。     

二级脾蒂离断法脾切除术在肝硬化门脉高压症脾功能亢进中的应用

目的:探讨肝硬化门脉高压症脾功能亢进轻中度脾肿大行腹腔镜下二级脾蒂离断法脾切除术的可行性、有救性和安全性.方法:对2009年1月至2010年12月施行腹腔镜下二级脾蒂离断法行脾切除治疗肝硬化门脉高压症脾功能亢进轻中度脾肿大25例患者的临床资料进行回顾分析.结果:除1例因大出血中转开腹外,均顺利完成手术.手术时间平均180 min,术中出血平均260 ml,无严重并发症.结论:肝硬化门脉高压症脾功能亢进轻中度脾肿大患者行腹腔镜下二级脾蒂离断法脾切除安全有效,值得临床推广应用.     

门静脉高压症三种断流手术方式及其疗效的探讨

目的评价因门静脉高压症行断流手术的方式及其疗效。方法对2000年1月至2015年1月十堰市太和医院肝胆胰外科诊疗中心收治的因门静脉高压症接受断流手术治疗的389病人进行随访,其中根据肝功能Child-Pugh分级A级345例、B级44例。据手术方法分三组:脾切除加贲门周围血管离断组157例;脾切除加食管下段吻合器横断吻合组139例;脾切除加食管下段联合胃近端切除组93例。结果 389例病人中无手术死亡和近期再出血。术后发生并发症31例,占8.0%。术后随访389例,随访12～52个月。术后1～3年内,行钡餐和胃镜检查,断流手术后再发静脉曲张的发生率为4.9%(19/389)。其中行脾切除加贲门周围血管离断术的157例,有15例(9.6%)表现为中重度曲张;行脾切除加食管下段吻合器横断吻合组139例中仅有4例(2.9%)表现为轻度静脉曲张;行脾切除加食管下段联合胃近端切除组93例均无再发静脉曲张。结论三种断流手术中接受脾切除+食管下段联合胃近端切除术的病人均未再发静脉曲张,具有良好的疗效。     

腹腔镜下二级脾蒂离断术治疗门静脉高压的临床效果与安全性分析

目的探讨二级脾蒂离断法应用于腹腔镜下脾切除联合贲门周围血管离断术治疗静脉高压中的临床效果。方法选取2012年1月至2016年10月本院收治的肝硬化门静脉高压患者70例为研究对象,均接受腹腔镜下脾切除联合贲门周围血管离断术治疗,根据不同脾蒂处理方法分组,以35例行传统脾蒂离断术患者为对照组,35例行二级脾蒂离断术患者为观察组。观察两组患者手术效果及并发症发生情况。结果所有患者均顺利完成手术,无中转开腹病例。观察组手术时间及术中出血量同对照组比较,差异无统计学意义(P0.05);观察组术后并发症发生率为11.43%,同对照组31.43%对比,明显较低,差异有统计学意义(P0.05)。结论门静脉高压患者接受腹腔镜下脾切除联合贲门周围血管离断术时,应用二级脾蒂离断法,效果确切,可显著提高手术安全性,减少并发症发生,值得推广。     

不同方法脾蒂离断脾切除术的临床分析

目的探讨二级脾蒂离断术在门静脉高压病人脾切除术中的作用。方法肝硬化门静脉高压脾肿大脾亢患者行脾切除加贲门周围血管离断术治疗共96例,其中行二级脾蒂离断术组52例（离断组,n=52）,传统脾蒂离断脾切除术组44例（传统组,n=44）。其中离断组在处理脾蒂时采用二级脾蒂离断法,传统组则采用一级脾蒂离断法。回顾性比较两组的手术相关指标,术后并发症及死亡率。结果传统组手术时间平均为（158.35±40.32）min,与离断组的（161.56±38.57）min无明显差异。两组死亡各1例,均为Child C级患者,术后并发MSOF所致。离断组的脾热和胰漏的发生率分别为13.5%（7/52）和0,传统组分别为31.8%（4/44）和11.4%（5/44）,二者差异显著（P〈0.05）,且传统组脾热的持续时间为（14.50±7.23）d,明显长于离断组的（2.40±1.14）d（P〈0.01）;其他并发症（膈下积液、门静脉血栓形成、MSOF）发生率及死亡率两组无明显差异（P〉0.05）。结论二级脾蒂离断术可降低门静脉高压脾切除病人脾热、胰漏的发生率,且不延长手术时间,是一种值得推广的手术方式,尤其对于脾脏较大的病人更为适合。     

腹腔镜巨脾切除贲门周围血管离断术治疗门脉高压症

目的:探讨腹腔镜巨脾切除术的可行性和安全性。方法:2003年10月至2008年12月我院为11例脾长径大于25cm的肝硬化门脉高压、脾功能亢进、食道胃底静脉曲张患者施行腹腔镜巨脾切除加贲门周围血管离断术。结果:11例均顺利完成腹腔镜手术,无中转开腹,手术时间平均250min,平均出血430ml。结论:只要具备相应的手术设备,熟练掌握手术技巧,腹腔镜巨脾切除加贲门周围血管离断术安全可行。     

贲门周围血管离断术技术规范专家共识（2013版）

有关外科治疗肝硬化门静脉高压症食管胃静脉曲张破裂出血的手术方法很多,且不同地区技术水平存在一定差别。为此,卫生和计划生育委员会卫生公益性行业科研专项“门静脉高压症治疗方法的合理选择和推广应用”专家组就贲门周围血管离断术规范化等相关临床问题进行充分研讨,形成以下共识：贲门周围血管离断术的手术适应证为肝硬化门静脉高压症伴有食管胃静脉曲张破裂出血,手术前应完善实验室和影像学检查,做好风险评估和术前准备,根据患者实际情况采用选择性或非选择性贲门周围血管离断术,对于是否切除脾脏尚存在争议。该专家共识特别探讨了原位脾切除技术及断流术有可能影响以后肝移植等问题。     

腹腔镜门静脉高压症贲门周围血管离断术的风险评估

目的 探讨腹腔镜在外科治疗门静脉高压症手术风险及手术技巧.方法 自 2011 年 6 月以来,46 例诊断为肝炎肝硬变、门静脉高压症、食管胃底静脉曲张,肝功能分级 Child A 级 32 例,B 级 14 例.术前胃镜检查了解食管胃底静脉曲张;门静脉彩超,了解门静脉有无血栓;上腹部 CT 增强扫描,了解脾脏大小,脾动、静脉走行,二级脾蒂分叉部位,脾门以及胃底、贲门周围曲张静脉分布情况.采用 4 孔法,取脐上 10 mm 戳孔为腹腔镜观察孔,左锁骨中线约与脐平线 12 mm 戳孔,为主操作孔;剑突左侧肋缘下 2 cm 处 5 mm 戳孔、左腋前线约与脐平线 12 mm 戳孔为辅操作孔,术者、一助均位于患者右侧.LS 技术操作我们采用前入路与侧入路结合方法,离断脾动脉、胃短血管时用前入路,游离脾肾、脾膈韧带,离断脾蒂时运用侧入路;贲门周围血管离断采用前入路.结果 全腹腔镜成功实施 38 例肝硬化门静脉高压症脾切除加贲门周围血管离断术,7 例术中出现不可控出血中转,1 例慢性胰腺炎术中无法分离出脾动脉中转.手术时间 142 ～ 218 min,平均（ 167 ± 44 ） min,术中出血80 ～ 280 ml,平均（ 113 ± 76 ） ml.采用预先结扎脾动脉,Endo Cut 闭合切割一级脾蒂或二级脾蒂,无出血、胰漏并发症,无死亡病例.术后第 2 天拔除胃管,第 3 天拔除腹腔引流管,术后 7 ～ 12 d 出院.结论 通过上腹部 CT,谨慎进行贲门周围血管离断术手术风险评估,正确的操作步骤,准确的分离层面,娴熟的腹腔镜下分离技巧,处理脾蒂血管动作精细,预防出血,保持视野清晰,尽管风险很大,腹腔镜手术治疗门静脉高压症还是安全、可行的.     

腹腔镜下巨脾切除联合贲门周围血管离断术15例

目的探讨腹腔镜巨脾切除联合贲门周围血管离断术的可行性、安全性及有效性。方法 2010年1月～2012年1月行15例腹腔镜下巨脾切除联合贲门周围血管离断术,取右侧斜卧位,超声刀自下向上离断脾结肠、脾胃、脾肾及脾膈韧带,游离脾动脉并结扎,线型切割缝合器（Endo-GIA）离断脾蒂,切除脾脏;切割缝合器切断胃左动静脉,继续游离胃周血管直至食道下端6～8 cm,完成断流。结果 12例腹腔镜下完成巨脾切除,3例因难以控制出血中转开腹。手术时间236～318 min,平均267.2 min;术中出血量200～1000ml,平均400 ml;术后住院时间5～12 d,平均7.8 d。1例出现胰漏,带管引流1个月后漏口愈合,无围手术期死亡。15例术后随访6个月,脾功能亢进纠正,钡餐示5例轻度食管胃底静脉曲张,余10例正常,未再出现呕血、黑便等症状。结论严格把握手术适应证,腹腔镜巨脾切除联合贲门周围血管离断术安全可行。     

Left-sided portal hypertension: Successful management by laparoscopic splenectomy following splenic artery embolization

INTRODUCTION

Left-sided portal hypertension is a rare clinical condition most often associated with a pancreatic disease. In case of hemorrhage from gastric fundus varices, splenectomy is indicated. Commonly, the operation is carried out by laparotomy, as portal hypertension is considered a relative contraindication to laparoscopic splenectomy (LS). Although some studies have reported the feasibility of the laparoscopic approach in the setting of cirrhosis-related portal hypertension, experience concerning LS in left-sided portal hypertension is lacking.

PRESENTATION OF CASE

A 39-year-old man was admitted to the Emergency Department for haemorrhagic shock due to acute hemorrhage from gastric fundus varices. Diagnostic work up revealed a chronic pancreatitis-related splenic vein thrombosis causing left-sided portal hypertension with gastric fundus varices and splenic cavernoma. Following splenic artery embolization (SAE), the case was successfully managed by LS.

DISCUSSION

The advantages of laparoscopic over open splenectomy include lower complication rate, quicker recovery and shorter hospital stay. Splenic artery embolization prior to LS has been used to reduce intraoperative blood losses and conversion rate, especially in complex cases of splenomegaly or cirrhosis-related portal hypertension. We report a case of complicated left-sided portal hypertension managed by LS following SAE. In spite of the presence of large varices at the splenic hilum, the operation was performed by laparoscopy without any major intraoperative complication, thanks to the reduced venous pressure achieved by SAE.

CONCLUSION

Splenic artery embolization may be a valuable adjunct in case of left-sided portal hypertension requiring splenectomy, allowing a safe dissection of the splenic vessels even by laparoscopy.     

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.     

脾切除联合贲门周围血管离断术治疗门脉高压症急性上消化道大出血27例临床治疗体会

目的探讨脾切除联合贲门周围血管离断术治疗门脉高压引起上消化道大出血的临床效果。方法回顾收治的27例门脉高压患者临床资料,分析脾切除联合贲门周围血管离断术治疗门脉高压的临床疗效。结果本组27例门脉高压患者,全部急诊行脾切除联合贲门周围血管离断术,24例疗效满意,围手术期无死亡病例。结论脾切除联合贲门周围血管离断术,止血可靠,既解决了脾亢问题,同时还解决了出血问题,且手术并发症少,操作较简单,易推广,为急诊手术首选。     

The different manifestation and outcome between pancreatitis and pancreatic malignancy with left-sided portal hypertension.

Left-sided portal hypertension can be induced by isolated splenic venous obstruction due to various etiologies, such as chronic pancreatitis and pancreatic malignancy. The patients may present with bleeding isolated gastric varices and hypersplenism in addition to their pancreatic lesions. In the past 3 years, we have encountered 24 patients with left-sided portal hypertension. They were diagnosed with an abdominal echogram, CT or splenoportography. Twelve patients had histories of acute pancreatitis for a few months to years. Eleven of them were found to have isolated gastric varices. Six of them underwent operation due to hypersplenism or pseudocyst. The postoperative courses were smooth and the gastric varices subsided after splenectomy. The other 12 patients with left-sided portal hypertension were diagnosed as having pancreatic malignancy. Only two of them were found to have isolated gastric varices. Seven of them received operations and only two patients with their tumors located at the pancreatic body and tail could be resected. The other 5 patients were diagnosed with abdominal CT and high serum CA 19-9. We concluded that the patients with left-sided portal hypertension can be suspected by isolated gastric varices without liver cirrhosis. The diagnosis can be confirmed by abdominal CT or splenoportography. The incidence of isolated gastric varices are significantly lower in the patients with pancreatic malignancy than those with chronic pancreatitis. The gastric varices subsided after splenectomy. The prognosis of pancreatic malignancy is poor and most of them are inoperable.     

Myeloproliferative disorders.

Forty-three operative procedures were performed on a population of 250 patients with myeloproliferative disorders, including polycythemia vera, myeloid metaplasia (MM) and chronic myelogenous leukemia (CML). The overall operative mortality was approximately 7% and the incidence of excessive bleeding which could be related to coagulopathy was 5%. Twenty-one patients with MM or CML underwent splenectomy for palliation of symptoms related to the enlarged spleen or hematologic problems. Eighty-four percent of the latter group were improved. Adverse hematologic effects which could be attributed to splenectomy in these patients were confined to two patients who developed marked thrombocytosis. Among the 23 patients with MM, 9 had portal hypertension. Three underwent portacaval shunt and one a splenorenal shunt for bleeding varices. One of the patients died of hepatic necrosis. Estimated hepatic blood flow determinations (EHBF) in 4 patients with portal hypertension demonstrated a marked absolute increase and an increase in the ratio of EHBF/Cardiac Index. Absence of any evidence of intrahepatic or extrahepatic obstruction in these patients and the demonstration that splenectomy relieved portal hypertension defined at surgery in 4 patients, suggests that augmented adhepatic flow contributes to portal hypertension in some cases. The review leads to the conclusions that: 1) Operative procedures in prepared patients with myeloproliferative disorders are not associated with prohibitive mortality and morbidity rates. 2) Splenectomy is indicated for patients with increasing transfusion requirements and symptomatic splenomegaly or hypersplenism and should be performed early in the course of disease. 3) When associated portal hypertension and bleeding varices are present, hemodynamic studies should be carried out to define if splenectomy alone, or a portal systemic decompressive procedure is indicated.     

胰源性区域性门静脉高压症的诊断和治疗:附11例报告

目的探讨胰源性区域性门静脉高压症的诊断方法和治疗效果。方法回顾分析11例胰源性区域性门静脉高压症的临床资料。结果11例表现为胃底静脉曲张、脾肿大和合并胰腺疾病，但肝脏正常行单纯脾切除术9例，脾切除加胰体尾切除术1例，其它手术1例。术后未发生严重并发症。随访10例，术后均未再出血。结论胰源性区域性门静脉高压症是术前、术中能够作出正确的诊断和根治的疾病。     

同期肝切除联合脾切除在肝癌合并门静脉高压患者中的应用探讨

目的探讨肝癌合并门静脉高压伴食管静脉曲张破裂出血的患者同期行肝癌切除和脾切除的安全性及可行性。 方法回顾性分析2002年1月至2018年1月期间42例肝癌合并门静脉高压伴食管静脉曲张破裂出血行肝脾联合切除患者的临床资料。记录手术时间、术中出血量及术后并发症发生例数。采用门诊复查或电话随访方式随访，随访截至时间为2022年1月。 结果开腹联合切除33例（78.6%），腹腔镜联合切除9例（21.4%）。其中8例行同期肝切除合并脾切除（19.0%），34例行同期肝切除合并脾切除同时加做贲门周围血管离断（81.0%）。术中出血量（771.4±500.2）ml，术中均未行肝门阻断；手术时间（5.6±2.6）h；42例患者术后病理学检查均证实为肝细胞癌。术后无围手术期临床死亡病例；术后3~6 d均恢复正常饮食。术后发生门脉系统血栓形成最为常见，共计出现32例（76.2%），单侧或者双侧胸腔积液21例（50.0%），肝周或者脾窝脓肿形成3例（7.1%），胆瘘2例（4.8%），严重门脉及脾静脉血栓形成致持续高胆红素血症1例（2.4%），后介入行肠系膜上动脉置管行肝素钠及尿激酶溶栓后好转。术后随访<5个月的3例（7.1%），超过1年的患者39例（92.9%），超过5年的患者9例（21.0%）。其中17例肿瘤复发或转移，并行进一步治疗（40.5%）；13例复查胃镜出现不同程度食管静脉曲张（31.0%）。 结论对于肝癌合并门静脉高压伴脾功能亢进及食管静脉曲张破裂出血的患者，可选择行肝脾联合切除，具有一定的安全性和可行性。     

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.     

Segmental portal hypertension.

Isolated obstruction of the splenic vein leads to segmental portal hypertension, which is a rare form of extrahepatic portal hypertension, but it is important to diagnose, since it can be cured by splenectomy. In a review of the English literature, 209 patients with isolated splenic vein obstruction were found. Pancreatitis caused 65% of the cases and pancreatic neoplasms 18%, whereas the rest was caused by various other diseases. Seventy-two per cent of the patients bled from gastroesophageal varices, and most often the bleeding came from isolated gastric varices. The spleen was enlarged in 71% of the patients. A correct diagnosis in connection with the first episode of bleeding was made in only 49%; 22% were operated on because of gastrointestinal bleeding, but the cause of bleeding was not found. The diagnosis should be suspected in patients with gastroesophageal varices, but without signs of a liver disease, especially if isolated gastric varices are found. The diagnosis is confirmed by portography.     

腹腔镜与开腹手术治疗门脉高压症的对比研究

目的探讨腹腔镜与开腹手术行脾切除联合贲门周围血管离断术治疗门脉高压症的手术效果。 方法回顾性分析2013年3月至2018年12月因门脉高压、脾大、脾功能亢进及食管胃底静脉曲张行脾切除术联合贲门周围血管离断术的患者资料,其中腹腔镜下手术21例(腹腔镜组),开腹手术50例(开腹组)。应用GraphPad Prism 6.0软件对所有数据进行分析。术中、术后相关指标采用( ±s)表示,独立样本t检验;并发症发生率采用χ²检验。P<0.05为差异有统计学意义。 结果与开腹组比较,腹腔镜组手术时间较长(P<0. 05),而术中出血量、切口长度、术后排气时间、镇痛药物使用次数、引流管拔除时间、术后住院时间、术后切口感染率均少于开腹组(P<0. 05);两组间的腹腔出血、腹、盆腔积液、肺部感染、胰瘘以及门静脉血栓形成差异无统计学意义(P>0.05)。 结论腹腔镜手术治疗门脉高压症行脾切除联合贲门周围血管离断术具有手术创伤小、术中出血少、术后恢复快、术后切口感染率低、住院时间短等优点,腹腔镜手术治疗门脉高压症是安全、可行的。