改良的限制性门腔静脉侧侧分流术

目的　探讨防止限制性门腔静脉侧侧分流术后吻合口扩大的方法。方法　对 3 2例肝硬变门脉高压症患者行限制性门腔静脉分流术 ,术中采用不吸收缝线连续缝合门腔静脉吻合口前后壁形成自然的限制环 ,以防止术后吻合口的扩大。结果　 3 2例患者于术后 3～ 3 6个月行彩超或螺旋CT检查 ,显示门腔静脉吻合口均无扩大 ;术后再出血率为 3 .1% (1/3 2 ) ,肝性脑病发生率为 6.3 % (2 /3 2 ) ;术后 ≤6个月时肝功能均有不同程度改善 ,与术前比较其差异有显著性 (P <0 .0 0 1) ;全部病例随访 6～ 49个月 ,随访率为 10 0 %。结论　改良的限制性门腔静脉侧侧分流术是治疗肝硬变门脉高压症的有效方法。     

门腔静脉架桥分流术与侧侧分流术疗效比较

门腔静脉侧侧分流术治疗门静脉高压症胃底食道曲张静脉破裂出血，虽能有效降低门静脉压力，再出血率低，但因分流量大，术后脑病和肝功能衰竭的发病率高。限制性门腔分流术后大多数吻合口仍然会随着时间的推移而扩大，部分还可能因吻合口张力较大而最终发生狭窄或形成血栓。本文报告使用带外支撑环的８ｍｍ口径Ｇｏｒｅ－Ｔｅｘ人工血管行门腔静脉架桥分流术治疗门静脉高压症病人２５例，并与同期门静脉侧侧分流组１４例比较。结果显示门腔侧侧分流组门静脉压力下降数值稍大于架桥分流组，但两组比较没有统计学意义（１．０４±０．４４ｋＰａ和０．８７±０．２６ｋＰａ，Ｐ＞０．０５）。两组术后再出血率及手术死亡率差异无显著性意义，但门腔静脉人工血管架桥分流术后脑病发生率显著低于门腔侧侧分流术组（８．０％和３５．７％，Ｐ＜０．０５），术后经下腔静脉行门静脉造影证明人工血管通畅率为９６％。初步结果表明门腔静脉人工血管架桥分流术对病人创伤较小，操作简便，术后脑病发生率低，是一种值得推荐的治疗门静脉高压症的手术方法。     

门腔静脉架桥分充术与侧侧分流术疗效比较

门腔静脉侧侧分流术治疗门静脉高压闰胃底食道曲张静脉破裂出血，虽能有效降低门静脉压力，再出血率低，但因分流量大，术后脑病和肝功能衰竭的发病率高。限制性门腔分流术后大多数吻合口仍然会随着时间的推移而扩大，部分还可能因吻全口张力较大而最终发生狭窄或形成血栓。本文报告使用带外支撑环的８ｍｍ口径Ｇｏｒｅ－Ｔｅｘ人工血管行门腔静脉架桥分流术治疗门静脉高压症病人２５例，并与同期门静脉侧侧分流组１４例比较。结果显     

限制性门腔静脉侧侧分流术治疗肝内型门静脉高压症

限制性(亦可称为小口径)门腔静脉侧侧分流术加脾切除术是我科治疗肝内型门静脉高压症的首选术式。所谓小口径是指将门腔静脉吻合口的直径限制在12mm以内。近年我们一般做成9mm并用一直径10mm的周环置于吻合处以防止术后吻合口扩大。动物实验及多年临床资料证实此术式的主要优点在于:由于限制了吻合口的分流量,既可有效地降低门脉压力,使食管胃底静脉曲     

限制性门腔静脉侧侧分流术后心脏功能的变化

肝硬化门脉高压症病人常伴有高动力循环 ,门体分流术后从内脏返回右心房血量突然增加 ,加重了高动力循环〔1〕。在这种情况下心脏功能可能受到影响 ,甚至导致心力衰竭〔2〕。我们用彩色多普勒超声诊断仪评价了限制性门腔静脉侧侧分流术后心脏形态及功能的变化。资料和方法1.一般资料 :本组 30例 ,男 2 3例 ,女 7例。年龄 2 7～ 6 8岁 ,平均 36岁。均为肝炎后肝硬化 ,肝功能分级Ⅰ级肝功 8例 ,Ⅱ级肝功 2 1例 ,Ⅲ级肝功 1例。行限制性门腔静脉侧侧分流术 +脾切除术。所有病人无心、肺、肾病史。急性出血病人及血红蛋白<10 0 g/L排除在外。病…     

金属环在分流术治疗门静脉高压症中的应用研究

金属环在分流术治疗门静脉高压症中的应用研究杨学文，武来兴，韩起廷，于铁民门静脉高压症食管胃底静脉破裂出血的治疗，目前仍在不断探索和改进之中。文献报道限制性门腔静脉侧侧分流术优于其它疗法［１］，但仍存在术后吻合口扩大的不足之处。为此，王宇等提出了新的限...     

附加限制环的限制性门腔静脉侧侧分流术

介绍附加限制环的限制性门腔静脉侧侧分流术的手术方式，报告了对１１０例接受该手术病人的随访结果。该手术方式临床效果满意，特别是术后脑病的发生率明显低于以往报道，其原因可能是由于该手术中放置的限制环，真正起到了持久限制分流的作用。附加限制环的限制性门腔静脉侧侧分流术是我科治疗门静脉高压症的首选手术方式。     

限制性门腔静脉侧侧分流术

限制性门胶静脉侧侧分流术是指根据术中测得的门静脉压力决定吻合口径大小,将其严格控制在12mm以下”。我科应用限制性门腔静脉侧侧分流术同时加脾切除术治疗门脉高压症已近30年,通过不断地摸索和探讨,感到此术式不失为口前治疗门脉高压的一种较好方法。我科始终将其作为首选术式治疗门脉高压症,由1960年至今已近600余例。本文将就手术操作要点加以介绍并对手术适应证等有关问题作简单说明。一、手术步骤及操作要点     

带蒂脾段腹膜后固定术联合改良Sugiura术治疗肝硬化门静脉高压症

目的 探讨带蒂脾段腹膜后固定术联合改良Sugiura术治疗肝硬化门静脉高压症的可行性.方法 对18例门静脉高压症行带蒂脾段腹膜后固定术联合改良Sugiura术患者临床资料及手术过程进行回顾性分析.结果 术后止血效果确切,无术后带蒂脾段坏死,术后所有患者食管下段静脉曲张消失或者明显好转,无术后门静脉系统血栓形成.吻合口狭窄发生1例.结论 带蒂脾段腹膜后固定术联合改良Sugiura术治疗门静脉高压症是一种合理可取的治疗方法,其疗效满意,操作并不复杂.     

门静脉高压症的围手术期处理

目的: 强调合理的门静脉高压症围手术期处理的重要性. 方法: 回顾总结400余例肝硬化门静脉高压症术前的各种检查方法、药物治疗、术式选择、手术操作要点以及恰当的术后处理. 结果: 本组病例在合理的门静脉高压症围手术期处理后,手术经过顺利,术后恢复良好. 结论: 最佳的围手术期处理可保证手术的安全性,降低手术后并发症的发生率.     

分流加断流联合手术治疗门静脉高压症

目的　探索分流加断流联合手术(联合术)治疗门静脉高压症的疗效。方法　通过对手术前后门静脉系血流动力学研究和前瞻性临床研究,对联合术治疗的150例门静脉高压症的临床资料进行分析。结果　联合术后近期无1例出血,远期再出血率为80%,术后肝性脑病发生率为48%,远期效果理想。血流动力学研究证明了本联合术的合理性。结论　脾肾分流加门奇断流联合术是治疗门静脉高压症的一种合理而可取的术式。     

Role of surgical portosystemic shunts in the era of interventional radiology and liver transplantation

BACKGROUND: In the present era of liver transplantation and transjugular intrahepatic portosystemic shunts, the role and choice of shunt surgery for portal hypertension was reviewed. METHODS: This retrospective study analysed the management of patients with portal hypertension in a tertiary liver transplant unit between June 1993 and May 2002. During this 9-year interval, 394 patients underwent endoscopic control of varices, 235 transjugular intrahepatic portosystemic shunts were inserted, 1142 liver transplants were performed, while only 29 patients needed a surgical portosystemic shunt. RESULTS: Twenty-nine shunt operations were performed in nine patients with cirrhosis, one patient with congenital hepatic fibrosis and 19 without parenchymal liver disease. There were 12 side-to-side lienorenal, nine mesocaval, three proximal lienorenal, two distal lienorenal, two portacaval and one mesoportal shunts. Encephalopathy was seen in five of 11 patients with a non-selective shunt, but did not occur after side-to-side or selective lienorenal shunt procedures. At a median follow-up of 42.5 months, one mesocaval shunt had thrombosed and one portacaval shunt had stenosed; both were successfully managed by percutaneous intervention. To date, six patients have died; two succumbed to postoperative complications, one of which was related to the shunt. CONCLUSION: Patients with Budd-Chiari syndrome and cirrhosis can nearly always be managed by a combination of endoscopy, interventional radiology and liver transplantation. In the rare instances when these therapies fail in patients with cirrhosis, a side-to-side lienorenal shunt is a good option.     

门静脉系统抗凝预防断流术后门静脉系血栓形成

目的 探讨门静脉高压症断流术后门静脉系血栓形成的预防方法。方法 将７１例肝硬化门静脉高压症患者分为２组：Ａ组３６例在断流术中经脾静脉分支插入抗凝管,术后行门静脉系统凝治疗;Ｂ组３５例断流术后未行门静脉系抗凝治疗。结果 术后３个月内彩超检查,Ａ组门静脉系均未见血栓形成,Ｂ组门静脉系血栓形成１３例（３７．１４％）。结论 门静脉系统抗凝治疗是预防门静脉高压症断流术后门静脉系血栓形成的有效方法。     

Portal venous decompression with H-type mesocaval shunt using autologous vein graft: a North American experience

BACKGROUND/PURPOSE: Portal hypertension in children often is caused by prehepatic venous obstruction or intrahepatic fibrosis without cirrhosis. This situation is uniquely amenable to shunting; this report details the experience of 3 North American centers with an H-type mesocaval shunt using autologous vein, which has been widely used in European centers. METHODS: Retrospective chart review was conducted of records from 1980 through 1999 at 3 North American institutions. Charts were reviewed for etiology of portal hypertension, diagnostic workup, preoperative management, operative results and complications, postoperative shunt patency, patient well-being, and eventual need for liver transplantation. RESULTS: Twenty patients were identified with prehepatic causes of venous obstruction undergoing shunt therapy. Eleven had portal venous thrombosis or cavernous transformation. Of these, 3 had umbilical catheters placed in the neonatal period. Five children had American-Indian cirrhosis, 1 had congenital hepatic fibrosis, and 3 had hepatic fibrosis associated with polycystic kidney disease. Patients presented at a median age of 3.7 years and underwent follow-up for an average of 4.3 years after surgery. These patients had an average of 3.6 bleeding episodes, (with 3.9 attempts at sclerotherapy) and received 3 units of blood preoperatively. Average age at operation was 8 years, average weight was 30 kg, and perioperative blood requirement was 200 mL. In general, patients did well postoperatively; 2 patients required reoperation for lymphatic leaks, and there was 1 death caused by a leaking G-tube, unrelated to shunt functioning. Two patients had transient encephalopathy postoperatively, and 1 patient had severe pancreatitis. All shunts remain patent, with good function and no further bleeding. CONCLUSIONS: These results are encouraging, and we would suggest that the H-type mesocaval shunt utilizing autologous vein be considered for wider use in pediatric patients with prehepatic cause of portal hypertension. An algorithm for the work-up of pediatric patients with variceal bleeding is presented, with the recommendation that shunt surgery be considered early in patients with a prehepatic or fibrotic causes of portal hypertension.     

Effect of portosystemic shunting on PGI2 and glucagon levels in humans.

OBJECTIVE: This study determined if the proposed mediators of splanchnic blood flow, prostacyclin and glucagon, were elevated in patients with portal hypertension undergoing portal systemic shunts. SUMMARY BACKGROUND DATA: Chronic portal hypertension results in increased portal venous pressure and increased splanchnic blood flow. Animal studies have suggested prostacyclin or glucagon, potent vasodilators, as potential mediators of this increased flow. Correlative clinical studies have been difficult to perform due to the wide variation in degree of portal-systemic shunting and the frequent association of parenchymal liver disease in patients with cirrhosis. METHODS: The authors measured portal and systemic hemodynamics in PGI2 and glucagon levels in patients with portal hypertension due to cirrhosis (partial portal systemic shunt) and Budd-Chiari syndrome (complete portal systemic shunt) undergoing portal systemic shunts and in porto normotensive patients undergoing exploratory laparotomies. RESULTS: PGI2 levels in portal hypertension were significantly increased over normal, and prostacyclin in Budd-Chiari patients were increased significantly over patients with cirrhosis. Both PGI2 and portal venous pressure decreased significantly after portal systemic shunting, and prostacyclin levels correlated directly with portal venous pressure (R = 0.37, p < 0.05). CONCLUSIONS: This is the first evidence in humans supporting the hypothesis that PGI2 is elevated in portal hypertension and is related to both the degree of portal venous obstruction and portal pressure. PGI2 probably has a role in the abnormal splanchnic hemodynamics of human portal hypertension.     

门腔静脉人工血管搭桥分流术治疗门静脉高压症

目的观察用门腔静脉间人工血管搭桥分流术治疗门静脉高压症患者的临床疗效,并与传统的门体分流术比较。方法采用带外支撑环的８ｍｍ口径聚四氟乙烯（ＧｏｒｅＴｅｘ）薄壁人工血管行门腔静脉间搭桥分流术,所用人工血管长度为２～３ｃｍ,共治疗２０例患者。结果搭桥分流术后门静脉压力下降幅度与同期１７例脾肾静脉分流术及１１例门腔静脉侧侧分流术相比差异无显著意义（０８３±０３１ｋＰａ,０８１±０５０ｋＰａ及１０２±０４５ｋＰａ,Ｐ＞００５）。三组患者全部获得随访,平均随访时间为１５～２８个月,手术死亡率及再出血率没有差别,但搭桥分流组术后脑病发生率显著低于门腔侧侧分流组（５０％及３６４％,Ｐ＜００５）。２０例患者术后近期均经下腔静脉行门静脉造影,人工血管通畅率为９５％,出院后１９例患者均经一次以上Ｂ超检查,随访已超过１５个月,人工血管均通畅。结论门腔静脉间小口径人工血管搭桥分流术对患者创伤小,操作简便,术后脑病发生率低,疗效比较确切     

Partial portacaval shunt: renaissance of an old concept.

BACKGROUND. Partial diversion of the portal system aims to reduce portal pressure sufficiently to prevent variceal hemorrhage but still maintain adequate hepatic portal flow. METHODS. Partial portacaval shunts were performed in 25 patients with cirrhosis with portal hypertension and esophageal varices, either as a primary procedure (n = 16) or for failure of endoscopic sclerotherapy (n = 9), with ringed polytetrafluoroethylene prostheses (8, 10, or 12 mm). RESULTS. All patients have now been followed up for at least 1 year. The operative mortality rate (2 months) was 4%. In 24 patients who survived beyond the initial perioperative period, there was no recurrence of variceal bleeding. Cumulative shunt patency (up to 4 years) is 96%. Acute encephalopathy was detected in two patients (8%), but no patients had signs of chronic encephalopathy. Intraoperative pressure measurements revealed a significant correlation between decreasing diameter of the graft and the percentage reduction of the portacaval pressure gradient. Selective angiography, performed 1 year after surgery, revealed that hepatopetal flow was maintained in 70% of patients with a 10 mm shunt. CONCLUSIONS. It is possible to achieve a partial portacaval shunt, related to the diameter of the prosthesis, that preserves hepatopetal flow in the majority of patients and is associated with a very low incidence of shunt thrombosis. This effectively prevents recurrent variceal bleeding and significant postoperative encephalopathy. The performance of subsequent orthotopic liver transplantation is not compromised. The technique is recommended, either as a primary procedure or when sclerotherapy has failed, in patients with good liver function who are unlikely to require early liver transplantation (grade A and some grade B cirrhosis).     

改良脾腔分流联合断流术在门静脉高压症治疗中的作用

目的 探讨改良脾腔分流联合断流术治疗门静脉高压症的安全性及疗效. 方法 回顾性分析135例接受脾切除、贲门周围血管离断联合脾腔静脉分流术的肝硬化门静脉高压症患者的临床资料. 结果 135患者手术全部成功,围术期死亡率2.2％( 3/135).110例获得随访,时间9月～12年,再出血率5.5％ (6/110),肝性脑病发生率6.4％(7/110),自由门静脉压力由术前的(36.9±3.2)cmH2O,下降至(32.0±1.5) cmH2O,差异显著(P＜0.01). 结论 脾腔分流联合断流术安全有效,是外科治疗门静脉高压症的优先选择之一.     

Results of left gastric vena caval shunt for esophageal varices: Analysis of one hundred clinical cases.

A new selective shunt operation, namely left gastric vena caval shunt, has been applied to 100 patients with esophageal varices, including 77 with cirrhosis of the liver and 19 with so-called idiopathic portal hypertension. Early death occurred in 3.0 percent and postoperative rebleeding from esophageal varices in 10.4 percent. The 5 year survival rate was 78.0 percent and the rehabilitation status of the surviving patients has been satisfactory, without any signs of hepatoencephalopathy. The shunt was proved to be patent in about 90 percent of the patients.     

Transjugular intrahepatic portasystemic shunt vs surgical shunt in good-risk cirrhotic patients: a case-control comparison

HYPOTHESIS: In good-risk patients with variceal bleeding undergoing portal decompression, surgical shunt is more effective, more durable, and less costly than angiographic shunt (transjugular intrahepatic portasystemic shunt [TIPS]). DESIGN: Retrospective case-control study. SETTING: Academic referral center for liver disease. PATIENTS: Patients with Child-Pugh class A or B cirrhosis with at least 1 prior episode of bleeding from portal hypertension (gastroesophageal varices, portal hypertensive gastropathy). INTERVENTION: Portal decompression by angiographic (TIPS) or surgical (portacaval, distal splenorenal) shunt. MAIN OUTCOME MEASURES: Thirty-day and long-term mortality, postintervention diagnostic procedures (endoscopic, ultrasonographic, and angiographic studies), hospital readmissions, variceal rebleeding episodes, blood transfusions, shunt revisions, and hospital and professional charges. RESULTS: Patients with Child-Pugh class A or B cirrhosis undergoing TIPS (n = 20) or surgical shunt (n = 20) were followed up for 385 and 456 patient-months, respectively. Thirty-day mortality was greater following TIPS compared with surgical shunt (20% vs 0%; P =.20); long-term mortality did not differ. Significantly more rebleeding episodes (P<.001); rehospitalizations (P<.05); diagnostic studies of all types (P<.001); shunt revisions (P<.001); and hospital (P<.005), professional (P<.05), and total (P<. 005) charges occurred following TIPS compared with surgical shunt. CONCLUSIONS: Operative portal decompression is more effective, more durable, and less costly than TIPS in Child-Pugh class A and B cirrhotic patients with variceal bleeding. Good-risk patients with portal hypertensive bleeding should be referred for surgical shunt.