门静脉高压症术式选择与探讨

治疗和预防曲张静脉破裂出血的措施主要包括三个方面：药物和内镜治疗为第一线治疗（first—line treatment）,分流术和断流术为第二线治疗（secondline treatment）,终末期肝病行肝移植治疗。     

腹腔镜改良Sugiura手术治疗门静脉高压症的疗效分析

目的探讨腹腔镜改良Sugiura手术（联合断流术）的手术方法、安全性和有效性。方法从2005年5月至2006年5月对5例肝硬化门静脉高压症、继发性脾功能亢进和上消化道出血患者进行了腹腔镜改良Sugiura手术,即脾切除、门奇静脉断流、食管下段管形吻合器横断和吻合术。结果5例腹腔镜改良Sugiura手术全部完成,无1例需中转开腹手术。手术时间3.5～5.0h,出血量100～400ml。术后住院10～15d。结论腹腔镜改良Sugiura手术在技术上是切实可行的,具有疗效确定、对机体影响小、并发症少和恢复快等优点。     

Late results of modified Mitchell procedure for the treatment of hallux valgus.

From a total of 153 patients (251 feet), 64 (41.8%) patients, who had had 105 modified Mitchell procedures, were clinically and radiographically examined with follow-up periods ranging from 15 to 24 years (mean, 21 years). Mean age at operation was 41 years (range, 12-64 years). The classic double osteotomies, which diverged slightly toward the plantar surface and the distal fragment, shifted laterally, and angled plantarward, were fixed with a smooth Kirschner wire. In this way, it was possible to achieve a reduction in the first intermetatarsal angle from an average of 22.5 degrees preoperatively to 7.7 degrees postoperatively, and the hallux valgus angle changed from an average of 33 degrees to 17 degrees, with an average shortening of the first metatarsal of 5.4 mm and an average lateral displacement of the first metatarsal head of 4.5 mm. In 67 feet (64%), the results were graded good to excellent; in 23 feet (22%), satisfied; and in 15 feet (14%), poor. The results were worse than the results obtained on the same patient population with a follow-up ranging from 2 to 11 years, with 97% good-to-excellent results reported. Pain over bunion caused by recurrence of the hallux valgus deformity was the main reason for this late deterioration of the results.     

TIPS、改良Sugiura术和TIPS加改良Sugiura术治疗门静脉高压症的疗效观察

目的　探讨TIPS、改良Sugiura术和TIPS加改良Sugiura术治疗门静脉高压症的临床疗效。　方法　对 90例门静脉高压症患者分别行TIPS(Ⅰ组 )、改良Sugiura(Ⅱ组 )和TIPS加改良Sugiura术 (Ⅲ组 )治疗。　结果　Ⅰ、Ⅱ和Ⅲ组近期并发症分别为 2 3 3 3 %、3 0 0 0 %和 2 0 0 0 % ,其中 ,出血复发率为 6 67%、10 0 0 %和 0 % ,肝性脑病为 16 67%、0 %和 13 3 3 % ,Ⅰ组病死率为 3 3 3 %。术后 1～ 3 6个月随访 ,Ⅰ、Ⅱ和Ⅲ组出血复发率分别为 3 4 4 8%、3 3 3 3 %和 3 3 3 % ;肝性脑病分别为 17 2 4 %、3 3 3 %和 3 3 3 % ,病死率分别为 2 0 69%、13 3 3 %和 3 3 3 %。Ⅲ组分流道通畅率高于Ⅰ组。　结论　TIPS与改良Sugiura术联合运用能有效地防治食管静脉曲张出血。     

TIPS,改良Sugiura术和TIPS加改良Sugiura术治疗门静脉高压症 …

目的 探讨ＴＩＰＳ、改良Ｓｕｇｉｕｒａ术和ＴＩＰＳ加改良Ｓｕｇｉｕｒａ术治疗门静脉高压症的临床疗效。地对９０例门静脉高压症患者分别行ＴＩＰＳ、改良Ｓｕｇｉｒａ和ＩＰＳ加改良Ｓｕｇｉｕｒａ术治疗。结果 Ⅰ、Ⅱ、Ⅲ组近期并发症分别为２３．３３％￣３０．００％和２０．００％,其中,出血复发率为６．６７％、１０．００％和０％,肝性脑为１６．６７％、０％和１３．３３％,Ⅰ组病死率为３．３３％,术后１￣３６个     

Extrahepatic portal hypertension: long-term results of surgical treatment.

Long-term results of surgical treatment were analysed in 42 patients with extrahepatic portal hypertension treated in the Department of Surgery, Institute of Haematology in Warsaw in the period 1971-1987. In all, 71 operations were carried out, and 20 patients were treated by endoscopic sclerotherapy of oesophageal varices. Recurrence of haemorrhage was found in 6 out of 11 patients 54% after venous shunting, in 13 out of 17 patients (76%) after treatment by ligation of oesophageal varices and in 32 out of 35 patients (91%) after splenectomy. Following repeated sclerotherapy of oesophageal varices, recurrence of haemorrhage occurred in 3 out of 20 patients (15%). During 17 years four deaths occurred (10%) none of which was due to haemorrhage from oesophageal varices. The authors conclude that the method of repeated sclerotherapy is presently the most effective way of preventing haemorrhage from oesophageal varices and consider this form of management as the treatment of choice in patients with extrahepatic portal hypertension.     

联合断流术术式的改进及其疗效的评价

目的探讨一种新的联合断流术治疗门静脉高压症引起的食管下端胃底曲张静脉破裂出血的安全性和有效性。方法1995年5月至2005年5月本院共对174例门静脉高压症患者施行了联合断流术,即脾切除、贲门周围血管离断和胃壁肌层、黏膜下层的血流阻断,后者应用吻合器或闭合器来完成。回顾分析其临床资料、手术方式、术后并发症、死亡率以及长期随访的结果。结果本组患者平均手术时间(3.9±1.0)h,平均输血量(598±650)ml,其中32.8%未输血,术后平均住院(17±7)d。术后并发症发生率为11.5%,手术死亡率为2.3%,无肝性脑病的发生。随访147例(86.5%),半均随访时间(36±23)个月。远期再出血率、肝性脑病发生率和死亡率分别为15.0%、2.0%和4.8%。结论应用该术式后患者发生并发症少,死亡率低,远期疗效满意,是防治门静脉高压症引起的食管下端胃底曲张静脉破裂出血的理想术式。术后加强胃黏膜的保护,止酸、抑酸对防治再出血有着积极的意义。     

分流加断流联合术治疗门静脉高压症的疗效评价

目的评价分流和断流联合术（脾肾分流加贲门周围血管离断联合术）治疗门静脉高压症的临床疗效及门静脉系血流动力学的变化。方法回顾分析1980—2005年入院的400例门静脉高压症患者分别施行分断流联合术（300例）和断流术（100例）的临床资料,并对部分患者手术前后行彩色多普勒显像、数字减影血管造影检查和术中自由门静脉压力测量。结果本组分断流联合术再出血率为5.9%,术后肝性脑病发生率为5.1%,术后1、3、5、10和15年生存率分别为94.9％、91.9%、84.9%、69.2%和45.1%。断流术后近期出血率为5.5%,远期再出血率为21.6%,肝性脑病发生率为4.5%。分断流联合术组术后自由门静脉压为（30.5±2.6）cm H2O,门静脉血流量为908 ml/min,均较术前降低,差异有统计学意义（P＜0.01）,并较断流术组显著降低和减少（P＜0.05）,但联合术与断流术后的门静脉血流量减少相比差异无统计学意义（P＞0.05）,联合术后门静脉头向侧支消失。结论从临床效果和血流动力学证实分断流联合术是一种治疗门静脉高压症合理而实用的术式。     

手助腹腔镜改良Sugiura 术治疗门静脉高压症的临床分析

目的：比较手助腹腔镜与开腹改良Sugiura术治疗门静脉高压症的近期临床疗效。 方法：2011年1月—2012年3月,将需行改良Sugiura术的56例门静脉高压症患者随机分为手助腹腔镜组和开腹组,每组28例,比较两组术中及术后各项临床指标。 结果：两组患者手术均获成功,无术中并发症发生。两组手术时间和术后并发症发生率差异无统计学意义（均P>0.05）,而手术切口、术中出血量、肛门排气时间、腹腔引流液量、术后住院天数比较,手助腹腔镜组均低于开腹组,差异均有统计学（均P<0.05）。术后随访1~13（平均7.32）个 月,两组食管胃底曲张静脉消除率均为100%,均未出现上消化道再出血。 结论：手助腹腔镜行改良Sugiura术既具有与开腹改良Sugiura术相同的临床疗效,又具有腹腔镜手术微创的优点。     

改良Sugiura手术加自体脾移植治疗门静脉高压症的临床研究

目的：评价改良Sugiura手术加自体脾移植治疗门静脉高压症的效果。方法：应用改良Sugiura手术力暗体脾移植治疗门静脉高压症患者45例（研究组）．与同时期45例行贲门周围血管离断术的患者（对照组）进行对比研究。结果：研究组术后无死亡病例，近期止血效果确切，随访时间0.5～4年，肝性脑病发生率为4．4％（2／45），再出血率为2．2％（1，45）；术后所有患者食管下段静脉曲张消失或明显好转；术后再出血率及静脉消失率两组比较差异均有统计学意义（P〈o．05）o研究组术后2个月血清Tuftsin和IgM水平下降不显著，术后随访移植睥块同位素显像呈阳性，而对照组无阳性显像。结论：改良Sugiura手术加部分自体脾移植手术操作较简单、再出血率低、并发症少且保留脾脏的免疫功能，是一种值得摊广的治疗门静脉高压痱手术方法。     

肝癌合并门静脉高压症的同期联合手术治疗(附19例报告)

目的　肝癌合并门静脉高压症同期联合手术治疗的方法和疗效。方法　回顾性分析1994年 8月至 2 0 0 2年 2月施行肝癌和门静脉高压症同期联合手术治疗 19例。结果　除 1例于术后 4周因并发肝肾综合征及上消化道出血死于多器官功能衰竭 (手术死亡率 5 .2 6 % )外 ,其余 18例皆康复出院 ,术后并发症发生率为 4 .1% (8 19)。随访中死亡 11例 ,死亡原因 :肝癌复发 3例 ,肝功衰竭 5例 ,上消化道出血 3例。术后 1、2、3年生存率分别为 79.8%、2 8.6 %、0 %。结论　只要合理掌握手术适应证和术式 ,对肝癌合并门静脉高压症施行同期联合手术治疗是安全的 ,可望延长病人的生存期     

Late results on the surgical treatment of Chagasic megaesophagus with the Thal-Hatafuku procedure.

BACKGROUND: Chagas' disease has a wide distribution in Central and South America. It is endemic in 21 countries, with 16 to 18 million persons infected and 100 million at risk. Surgical treatment of achalasia from Chagas' disease is the first choice in advanced stages. The aim of this study was to analyze the late clinical followup of 50 patients operated on for Chagas megaesophagus with the Thal-Harafuku procedure. STUDY DESIGN: During the period of January 1966 to January 1993, 50 patients suffering from advanced achalasia from Chagas' disease were submitted to the Thal-Hatafuku procedure. The patients answered a questionnaire concerning the most relevant postoperative symptoms. The Thal-Hatafuku procedure was performed as the first surgical option (46 patients), and on reoperations because of failure of other surgical techniques (4 patients). RESULTS: The mean followup was 63.11 months for the 44 patients with longterm followup. Postoperative complications included surgical site infection (3 of 50 patients), urinary infections (3 of 50 patients), atelectasis (2 of 50 patients), pleural effusion (2 of 50 patients), and deep venous thrombosis (1 of 50 patients). The main symptoms found in the postoperative period were dysphagia (20 of 44 patients), heartburn (11 of 44 patients), vomiting (13 of 44 patients), and retrosternal pain (6 of 44 patients). Eleven patients of the 44 remained asymptomatic at the end of the followup period. Outcomes were analyzed according to the modified Visick classification. Visick classes I and II represented 25% and 27.3%, respectively. Eighteen patients (40.9%) were classified as Visick III. CONCLUSION: We conclude that the Thal-Hatafuku operation is a therapeutic option that should be considered in the treatment of achalasia of the esophagus secondary to Chagas' disease, in advanced cases.