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。     

胰源性门静脉高压症致消化道出血及其诊治

胰源性区域性门静脉高压症主要表现为脾大、胃底静脉曲张并可致消化道出血,临床较为少见。多种胰腺疾病如慢性胰腺炎、胰体尾肿瘤等均可导致此症,其病理基础为上述胰腺病变导致脾静脉狭窄或栓塞,而脾动脉供血正常,脾充血肿大,脾静脉血回流由胃短静脉代偿,致胃底部形成区域性门静脉高压症。对于肝功能正常而合并脾大的消化道出血者应考虑到胰源性区域性门静脉高压症的可能。脾切除可有效控制出血,治疗上还应考虑针对胰腺原发疾病的治疗,该病的预后主要取决于胰腺的原发疾病。     

胰源性门脉高压症的研究进展

胰源性门脉高压症是以上消化道出血为主要表现的临床比较少见的疾病。引起胰源性门脉高压症的原因很多，主要是急、慢性胰腺炎，胰腺假性囊肿，胰腺肿瘤，造成脾静脉回流受阻，使左侧门静脉压力升高，胃底静脉曲张。治疗上主要针对病因处理，脾切除和原发胰腺疾病的处理（包括胰体尾切除）是治愈本病的关键。     

胰源性门静脉高压症7例诊治分析

目的:探讨胰源性门静脉高压症的临床诊断和治疗方法。
方法:回顾分析收治的7例胰源性门静脉高压症患者的临床资料。6例有慢性胰腺炎病史，其中4例合并假性囊肿，1例为胰体尾部癌。术前肝功能检查均正常。5例出现上消化道出血，胃镜检查发现胃底静脉曲张。
结果:7例均行手术治疗，单纯脾切除2例，胰周坏死组织清除+脾切除+门奇静脉断流术1例，胰尾囊肿切除+脾切除术1例，假性囊肿内引流+脾切除术2例，胰体尾切除+脾切除术1例。术后随访胃底静脉曲张消失，均未再发生出血。
结论:胰源性门静脉高压症手术治疗效果令人满意，对有症状的患者，在治疗胰腺疾病的同时应附加脾切除术。

     

胰源性门静脉高压症诊治

胰源性门静脉高压症又名胰源性区域性门静脉脉高压症,又称为左侧肝外门静脉高压症(LEPH),是指脾静脉血回流受阻引起的胃脾区域静脉压力增高,造成胃黏膜下静脉曲张,继而可发生上消化道出血,是上消化道出血少见原因之一,临床医生对此病认识不足,常常造成误诊和漏诊,现就其诊治经验浅谈如下。一、病理生理解剖学显示脾静脉紧贴在胰腺后方,与胰体尾部伴行,部分脾静脉在胰体尾部常被胰实质包绕1/2~3/4周,因此,任何胰腺病变(尤其是胰体尾部病变)都可能使脾静脉受到累及。脾静脉回流一旦受阻,脾脏淤血肿大,表现为脾功能亢进。随着脾静脉压进一步…     

胰源性门静脉高压症的诊断及外科治疗

胰源性门静脉高压症是一种少见的门静脉高压症类型,脾静脉血栓形成或梗阻是其根本原因,其原发疾病包括胰腺炎症、肿瘤及其他胰腺疾病,可引起单纯门静脉脾胃区域的压力增高,临床上可根据病人临床表现、生化检查和影像学手段等进行综合诊断。外科治疗应采用个体化的治疗原则,胰腺原发疾病的治疗是基础及关键,对于胃肠道曲张静脉出血,脾切除术是有效的治疗手段,静脉曲张严重者可加做断流术,对于病变在胰体尾的胰源性门静脉高压,可在解除胰腺病变的同时切除脾脏,但不主张预防性脾切除术,无法耐受手术病人可考虑介入治疗。     

胰源性门静脉高压症研究现状

胰源性门静脉高压症是由胰腺疾病引起的门静脉高压,临床上较为罕见,存在胰腺原发疾病、胃底静脉曲张、脾肿大和肝功能正常是其特征性表现。脾切除是有症状的胰源性门静脉高压症的主要治疗手段。预后主要取决于胰腺原发疾病,治疗原发病和防治并发症(主要是上消化道出血)是其治疗的关键。     

门静脉高压症巨脾切除术的技术改进和临床应用

目的:总结肝硬化门静脉高压症巨脾原位切除术的临床应用体会。方法:对2006年1月至2012年5月期间因肝硬化门静脉高压症施行外科手术348例病人的临床资料进行分析,详细描述原位脾切除术的手术过程。结果:所有病人均施行原位脾切除术,即先离断脾门后游离脾周韧带,术中的关键技术是建立胰后间隙。与传统脾切除术相比,原位脾切除术更有利于避免术中难以控制的出血和胃壁、胰腺等副损伤,减少手术并发症。结论:肝硬化门静脉高压症巨脾切除的顺序均应先离断脾蒂再处理脾周韧带,即原位脾切除术,较传统脾切除术更合理、安全。     

胰源性门静脉高压症治疗进展

胰源性门静脉高压症（pancreatic sinistral portal hypertension,PSPH）是由胰腺疾病导致脾静脉回流受阻而引起的一种临床综合征,其病因主要包含急、慢性胰腺炎,胰腺肿瘤以及胰腺手术相关的医源性因素。PSPH患者大多表现为孤立性胃静脉曲张、脾肿大和脾功能亢进,肝功能多正常,胃底曲张静脉破裂所致上消化道出血为其最严重的临床表现。PSPH的治疗可分为脾胃区门静脉高压症的治疗,包括密切随访、药物治疗、内镜治疗、脾动脉栓塞术、脾切除术等;对胰腺原发疾病的治疗主要针对急性、慢性胰腺炎以及胰腺肿瘤;特别是与胰腺手术术式相关的PSPH值得关注。     

对胰源性门静脉高压症的认识

胰源性门静脉高压症又名胰源性区域性门静脉脉高压症．又称为左侧肝外门静脉高压症（1eftsided extrahepatic portal hypertension，LEPH），指脾静脉血回流受阻引起的胃脾区域静脉压力增高，造成胃黏膜下静脉曲张，继而可发生上消化道出血，是上消化道出血少见原因之一．临床医师对此病认识不足，常造成误诊和漏诊，现就此认识浅谈如下。     

左侧肝外门静脉高压症

总结了左侧肝外门静脉高压症１３例的诊断治疗经验．各种胰腺疾病所致脾静脉栓塞是本病的直接原因．其发生占胰腺疾病的６．６％，本病的临床重要性在于合并上消化道出血，严重的可以致死，其出血的发生率为４６％。胰腺疾病合并上消化道出血者应首先想到本症的可能。对无出血的病人术前作出诊断较难．脾切除术可以有效地控制出血．无出血病人是否需要作预防性脾切除应视原发病情况而定．     

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.     

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.     

原位脾脏切除术256例体会

目的 总结原位脾脏切除术比较于传统脾脏切除术的优越性和不足。方法 对1999年7月至2002年5月实施的256例原位脾脏切除术的临床资料进行分析。结果与传统的脾脏切除术相比，原位脾脏切除术通过在保持脾脏原位状态下离断胃短血管和脾门血管，更有利于保护胃壁、胰尾、脾静脉等重要结构，预防胃瘘、胰尾瘘、术后大出血、脾静脉及门静脉血栓等严重并发症。尽管该术式操作平面深在，对术者的技术要求高，但本组资料显示，脾脏原位状态下完成胃短血管离断术和脾门各血管处理的成功率分别为98．0％和96．5％。结论 原位脾脏切除术更适用于门静脉高压症时巨大脾脏的切除，与传统的脾切除术相比，创伤性更小，安全性更高。     

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.     

Significance of splenic vein thrombosis in chronic pancreatitis

BACKGROUND: Splenic vein thrombosis leading to sinistral portal hypertension and variceal bleeding is a complication of chronic pancreatitis. The management of these patients without variceal bleeding remains controversial. METHODS: A total of 157 patients with chronic pancreatitis were managed consecutively in our center between January 1996 and December 2005. Thirty-four patients with chronic pancreatitis were diagnosed to have splenic vein thrombosis. RESULTS: The incidence of splenic vein thrombosis in patients with chronic pancreatitis was 22%. Fifteen percent of patients with chronic pancreatitis and splenic vein thrombosis presented with gastroesophageal variceal bleeding. Nine patients underwent splenectomy along with pancreatic procedures and 21 patients underwent pancreatic procedures only. Adding splenectomy to the pancreatic procedure did not lead to increased morbidity or mortality. CONCLUSION: Splenectomy should be added to the pancreatic procedure in patients who have evidence of portal hypertension on preoperative evaluation, especially if gastric varices are found.     

Isolated Gastric Varices Resulting from Iatrogenic Splenic Vein Occlusion: Report of a Case

Iatrogenic splenic vein occlusion is known to be a rare cause of left-sided portal hypertension. We herein describe the clinical course of a 43-year-old woman with isolated gastric varices, which proved to be attributable to a segmental splenic vein resection during an operation for a benign pancreatic tumor 11 years previously. Seven years after the initial operation, prominent gastric varices due to left-sided portal hypertension were first noted. During the follow-up period of 4 years, she had no episodes of gastrointestinal hemorrhaging. Although the size of the gastric varices did not change, she decided to have a splenectomy considering the potential risk of variceal hemorrhaging. It may be reasonable to perform a splenectomy concomitantly when the splenic vein is to be resected or ligated during pancreatic surgery to avoid the future development of left-sided portal hypertension. However, the role of prophylactic surgery in asymptomatic patients with iatrogenic splenic vein occlusion remains to be determined. Received: June 3, 2002 / Accepted: November 19, 2002 RID="*" ID="*" Reprint requests to: Y. Ku     

Sinistral (left-sided) portal hypertension

Between 1953 and 1988, 21 patients with splenic vein thrombosis (SVT), 12 of whom had sinistral portal hypertension (SPH) were treated at our institution. SVT was identified at autopsy in nine patients. Twelve additional patients presented with SPH: bleeding esophageal varices, SVT and normal hepatic function. SVT was caused by pancreatic neoplasm (5), chronic pancreatitis (5), and pancreatic pseudocyst (2). SVT was diagnosed by splanchnic angiography, splenoportography, computerized tomography, and ultrasonography. Gastric varices were diagnosed by endoscopy (10) and barium swallow (2). Splenectomy was performed as primary therapy in 10 patients. Three of these 10 had en block distal pancreatectomy. Two high-risk patients had splenic artery embolization, one as a prelude to splenectomy performed 48 hours later and the other as definitive therapy. One splenectomized patient continued to bleed. No further bleeding occurred in 10 splenectomized patients in follow-up from 1 week to 14 years. Sinistral portal hypertension is a clinical syndrome of splenic vein thrombosis caused by pancreatic pathology and manifests as bleeding gastric varices in patients with a patent portal vein and normal hepatic function. Splanchnic arteriography is necessary for accurate diagnosis. Splenectomy is the effective treatment of choice.     

Laparoscopic subtotal splenectomy

BACKGROUND: Since 1979, we have been studying subtotal splenectomy. This procedure was used in over 200 patients to treat splenic trauma, portal hypertension, myeloid metaplasia due to myelofibrosis, Gaucher disease, chronic lymphocytic leukemia, retarded growth, and sexual development associated with splenomegaly, and disorders of the pancreatic tail. On the basis of our clinic experience with laparoscopic splenectomy with and without splenic autotransplantation, open subtotal splenectomy, and after a training period with laparoscopic conservative splenic operations on animals, this communication presents laparoscopic subtotal splenectomy as a new treatment of severe pain due to ischemia of the spleen. PATIENTS AND METHODS: Two patients with severe splenic pain due to ischemia provoked by vascular obstruction of the spleen were successfully treated by laparoscopic subtotal splenectomy, with preservation of the upper splenic pole supplied only by the gastrosplenic vessels. RESULTS: This procedure was safely conducted with minor bleeding and no technical difficulties or complications. The postoperative follow-up of 5 and 21 months has been uneventful and the pain disappeared since the first postoperative day. CONCLUSIONS: It is feasible and safe to perform subtotal splenectomy by laparoscopy. This procedure seems to be a good treatment for pain due to splenic ischemia.