三种术式治疗门静脉高压症疗效比较

近年来，针对门静脉高压症合并食管胃底曲张静脉破裂出血的合理术式的探索在不断进行。1986年1月至2001年12月，我院采用断流术、分流术、分流断流联合术治疗肝硬变门静脉高压症患者318例。现对治疗结果进行对比分析，以探讨治疗该病的良好手术方式。     

门静脉高压症的围手术期护理

目的探讨门静脉高压症围手术期的一般护理及并发症的护理方法。方法总结2003-01～2010-12门静脉高压症手术33例的围手术期护理措施。结果 33例门静脉高压症手术患者经整体护理后,并发症的发生明显减少。结论精心的围手术期护理能提高门静脉高压症手术患者治愈率,减少并发症和降低病死率。     

分流断流联合术治疗肝硬化门静脉高压症的疗效观察

目的分析分流断流联合术治疗肝硬化门静脉高压症的疗效。方法选取2012年11月~2015年4月我院收治的肝硬化门静脉高压症患者72例作为研究对象,按照不同治疗方法将其分为对照组和研究组,各36例。对照组单独采用断流术,研究组采用分流断流联合术,并比较两组患者的疗效。结果治疗后,研究组自由门静脉压(FPP)显著低于对照组,差异有统计学意义(P0.05);对照组并发症发生率明显高于研究组,差异有统计学意义(P0.05)。结论肝硬化门静脉高压症采用分流断流联合术治疗的疗效显著,且安全可靠,值得临床使用和推广。     

门静脉高压症上消化道出血25例外科治疗

目的 探讨门静脉高压症上消化道出血恰当的手术治疗时机和围手术期处理的重要性。方法 1995—01／1998—12收治门静脉高压症上消化道出血病人25例。全组病人均施行脾切除及门奇断流术。其中急诊手术3例，相对择期手术于止血后1周内手术11例，2周内8例，3周内3例。结果 全组病人近期止血率100％，肝功能均有不同程度改善，无手术死亡病例。结论 门静脉高压症上消化道出血病人选择恰当的手术时机和稳妥的围手术期处理是提高救治成功率的关键。     

脾肾静脉分流术联合门奇静脉断流术治疗门静脉高压症临床疗效观察

目的 评价脾肾静脉分流术联合门奇静脉断流术治疗门静脉高压症的疗效.方法 50例门静脉高压症患者分别采用脾肾静脉分流术联合门奇静脉断流术（A组,26例）和单纯门奇静脉断流术（B组,24例）进行治疗,比较两组患者术后肝功能、凝血功能、门静脉压力（FFP）以及胃食管静脉破裂出血再发生率等.结果 A组术后胃食管静脉破裂再出血发生率仅3.8％、FFP为（21.5±2.6）mmHg,B组分别为20.8％、（24.4±3.7） mmHg,两组相比,P均＜0.05.手术前后两组患者的肝功能分级、凝血功能相比,P均＞0.05.结论 脾肾静脉分流术联合门奇静脉断流术治疗门静脉高压症临床疗效明显,而且其治疗效果优于单纯门奇静脉断流术.     

择期断流术治疗门静脉高压症348例报告

1990年1月至1999年12月，我们采用择期断流术治疗348例门静脉高压症(PHT)患者。现报告如下。     

经颈内静脉肝内门体分流术加断流术治疗门静脉高压症

经颈内静脉肝内门体分流术（TIPS）已被成功地用于治疗门静脉高压症伴食管静脉曲张破裂大出血和腹水。TIPS与断流术的联合应用能显著减少食管静脉曲张再出血率，提高门静脉高压症患者的生存率。本研究进一步总结TIPS加断流术联合治疗的随访结果，深入探讨这一治疗模式的临床价值。     

冷沉淀在门奇静脉断流术治疗门静脉高压患者中的应用

目的探讨使用冷沉淀对降低门奇静脉断流术围手术期大出血等风险的作用,及其对术后并发症的影响。方法68例门脉高压患者实施脾切除、门奇静脉断流术。患者随机分为两组,34例为冷沉淀使用组,于术中输注冷沉淀10单位;34例为对照组,术中不使用冷沉淀。比较两组患者术后创面出血情况、凝血酶原时间、术后恢复情况及消化道再出血、门静脉系统血栓等并发症的发生率等。结果与对照组比较,输注冷沉淀的门奇静脉断流患者,术后创面失血明显减少,腹腔内及消化道大出血的发生率降低。患者恢复较快,术后平均住院日低于对照组。门静脉系统血栓等并发症不高于对照组。结论门奇静脉断流术中输注冷沉淀可改善凝血机能,有效预防围手术期大出血的发生,有助于患者术后恢复。其使用未增加门静脉系统血栓等并发症的发生,安全有效。     

脾切除贲门周围血管离断术治疗470例门静脉高压症疗效分析

目的总结脾切除贲门周围血管离断术治疗不合并肝癌及胆管癌的门静脉高压症患者的疗效。方法对不合并肝癌及胆管癌的门静脉高压症患者行脾切除贲门周围血管离断术并随访470例,其中肝炎后肝硬化436例,占92．8％。结果出血患者424例,手术止血率为993％（421／424）,围手术期病死率为1．4％（6／424）,主要死亡原因是上消化道出血、肝肾功能衰竭;急症及择期手术424例,预防手术46例,预防手术嗣手术期无死亡。平均随访时间4年,出血患者术后复发出血率为3．2％（15／470）,预防手术后无出血,肝性脑病发生率为1．9％（9／470）。结论脾切除贲门周围血管离断术防治门静脉高压症引起的上消化道出血效果好。合理选择手术适应证及手术时机、完全彻底断流、术后早期抗凝及近端脾静脉结扎预防术后肝外门静脉系统血栓形成是提高手术疗效的必要措施。     

肝硬化门脉高压症70例术前肝功能评估及术后并发症分析

门静脉高压症所致的上消化道出血是肝炎后肝硬化致死性并发症之一 ,本文对 70例肝炎后肝硬化门脉高压症手术治疗患者的术后存活率进行前瞻性分析 ,旨在探讨此类患者手术治疗的适应证及手术时机的选择问题 (外科术式及其它技术因素未列入本研究范畴 )。材料与方法一、对象70例手术治疗的患者为近 7年来本院肝病科诊治的乙型肝炎肝硬化合并门静脉高压症而在本院或外院行相关手术者 ,其中男性 5 4例 ,女性 16例。年龄最轻者 3 8岁 ,最高者 62岁。术式选择 :单纯脾切除 4例 ;断流术 (脾切除加贲门周围血管离断术 ) 5 4例 ;分流术 12例。术期选择…     

Transabdominal gastroesophageal devascularization without esophageal transection for emergency treatment of variceal hemorrhage.

BACKGROUND: The Suguira procedure is an effective non-shunting operation to treat life-threatening hemorrhage from esophageal or gastric varices. The goal of esophageal transection is interruption of submucosal varices, but this leads to high morbidity and mortality rates from esophageal fistulization. AIM: To evaluate a variant of this procedure in which the esophagus is not transected, but the varices are underrun from outside the lumen. METHODS: During the last four and a half years, we performed this modified gastroesophageal devascularization with or without splenectomy in 18 patients as emergency treatment of bleeding esophageal and gastric varices. The data were analyzed retrospectively. RESULTS: Bleeding was controlled in all patients. Three patients with Child's class C disease undergoing emergency surgery died during the early postoperative period. Rebleeding rate was 17% (3 patients). The overall survival was 72.2% (13 of 18). No patient had encephalopathy over a mean follow up of 30 months. CONCLUSION: Gastroesophageal devascularization with variceal under-running without esophageal transection is an effective and safe alternative to shunt surgery in the emergency situation.     

Transabdominal gastroesophageal devascularization without transection for bleeding varices: results and indicators of prognosis

BACKGROUND: Esophagogastric devascularization is an operation that can be performed for endoscopically uncontrolled variceal bleeding in hospitals having only basic surgical instruments and is therefore an appropriate procedure for small hospitals in developing countries. The aim of this study was to analyze one hospital's experience of this operation in consecutive patients with variceal bleeding. METHODS: Between 1996 and 2003, 45 patients (30 male, 15 female) who had a mean age of 40 years (range 7-78 years) underwent devascularization procedures. Of the 45, 23 had cirrhosis and 22 had non-cirrhotic portal hypertension (11 extrahepatic portal venous obstruction, 11 non-cirrhotic portal fibrosis), and 18 patients had emergency procedures and 27 were elective. Mortality, morbidity, rebleeding rates and the prognostic factors for death were assessed. RESULTS: Elective and emergency mortality was one (3.7%) and 11 (61%) patients, respectively. There was no rebleeding in hospital. At follow up (mean 48 months, range 3-92 months) overall survival in patients with cirrhosis was 7 out of 20 and in patients with non-cirrhotic portal hypertension was 19 of 21. Five (17%) had recurrent variceal hemorrhage, of whom three, all cirrhotic patients, died. Preoperative prognostic indicators for death were emergency surgery, a Child-Pugh score >or=10, preoperative blood transfusion >or=20 units and renal failure. CONCLUSIONS: Gastroesophageal devascularization effectively controls variceal bleeding especially in non-cirrhotic patients with portal hypertension. In the elective situation it carries a low mortality and rebleed rate. In emergencies the prognosis is poor with advanced cirrhosis, following large quantities of blood transfusion and deranged renal function. It is suggested that this operation be offered especially to non-cirrhotic patients in hospitals in developing countries where facilities for more sophisticated procedures are not available.     

Evaluation of the effects of combined endoscopic variceal ligation and splenectomy with pericardial devascularization on esophageal varices

INTRODUCTION In patients with portal hypertension, collaterals should be established to reduce the high portal pressure, and the hemodynamic indicators of such collaterals have been used for the evaluation of therapeutic effects. According to the location…     

经皮经肝曲张静脉栓塞治疗断流术后食管胃底静脉破裂出血的疗效

目的 研究以组织胶为主要栓塞材料,采用经皮经肝曲张静脉栓塞术(PTVE)治疗和预防门奇静脉断流术后食管胃底静脉曲张破裂出血的临床疗效.方法 2006年11月至2008年9月,对22例曾行断流术再发食管胃底静脉曲张破裂出血的患者行PTVE组织胶栓塞(n=10)或内镜下硬化剂(EIS,n=12)治疗,随访两组患者治疗后再出血率、死亡率、治疗前后静脉曲张和肝功能以及PTVE治疗组患者在曲张侧支静脉栓塞前后门静脉压力的变化.结果 ①在平均12.5个月的随访期内,PTVE治疗组患者再出血率和死亡率分别为1/10和0;EIS治疗组随访13.4个月,患者再出血率和死亡率分别为7/12和3/12,两组问差异有统计学意义(P<0.05).②PTVE和EIS治疗均可显著减轻食管和胃底静脉曲张程度.③对有门静脉血栓患者,PTVE联合门静脉球囊成形术,可以改善肝脏门静脉血供.④PTVE和EIS治疗均未加重肝功能损伤.结论 对门奇静脉断流术后食管胃底静脉破裂出血的患者,采用以组织胶为主要栓塞材料的PTVE治疗的疗效优于EIS治疗.     

Esophageal variceal ligation for acute variceal bleeding: results of three years' follow-up.

BACKGROUND/AIMS: Endoscopic variceal ligation is widely accepted as the optimum endoscopic treatment for esophageal variceal hemorrhage. However, the rebleeding course and long-term outcome of patients with esophageal variceal hemorrhage after ligation have been poorly defined. Therefore, we conducted a long-term follow-up study to delineate the outcome of ligation. METHODS: Twenty-one liver cirrhotic patients with endoscopically proven esophageal variceal hemorrhage were treated by endoscopic variceal ligation. These patients received regular follow-up and detailed clinical assessment of at least 24 months. RESULTS: Twenty-one eligible patients were followed up for a mean of 44.45 months (range 33.5-64 months). The mean number of sessions required to obtain eradication was 3.57+/-1.99 (range 1-8). Esophageal varices could be obliterated within 11.57+/-6.8 weeks (range 3-30). The percentage of variceal recurrence during follow-up was 57.14% (12/21) after endoscopic variceal ligation. Recurrence were observed in a mean of 34 months (median 29 months). Rebleeding from esophageal varices appeared in four patients (19.04%). The appearance rates of portal hypertensive gastropathy and fundal gastric varices after varice obliteration were found to be 45.45% (5/11) and 25% (3/12), respectively. CONCLUSIONS: Based on the results of long-term follow-up of endoscopic variceal ligation, although the percentage of variceal recurrence was high, endoscopic ligation achieved variceal obliteration faster and in fewer treatment sessions. Furthermore, endoscopic variceal ligation had a lower rate of rebleeding and of development of fundal gastric varices, but high portal hypertensive gastropathy.     

Comparison of the long-term results of distal splenorenal shunt and esophageal transection for the treatment of esophageal varices

BACKGROUND/AIMS: This study was undertaken to evaluate the comparison of long-term results of distal splenorenal shunt and esophageal transection for the treatment of esophageal varices. METHODOLOGY: Twenty-four cirrhotic patients underwent distal splenorenal shunt, and 19 cirrhotic patients underwent esophageal transection with complete variceal eradication and follow-up for at least 3 years. RESULTS: No recurrent varix was observed in the distal splenorenal shunt group. The cumulative recurrence rates of varices in the esophageal transection group were 31.6%, and 52.5% at 5 and 10 years, respectively. The cumulative rates of hyperammonemia at 5 and 10 years were significantly higher in the distal splenorenal shunt group (30.4%, 30.4%) than in the esophageal transection group (0%, 5.6%) (P = 0.009). The cumulative survival rates in the distal splenorenal shunt group versus the esophageal transection group were 90.9% versus 94.7%, and 85.2% versus 81.7% at 5 and 10 years (NS). CONCLUSIONS: These results suggest that distal splenorenal shunt is more effective than esophageal transection in preventing recurrence of esophageal varices, but is associated with a higher incidence of hyperammonemia.     

护理补充干预对肝硬化患者食管静脉曲张套扎术后影响

目的观察护理补充干预对预防肝硬化伴食管静脉曲张套扎术后影响的效果,为临床护理工作提供参考。 方法收集上海交通大学医学院附属瑞金医院北院消化内科2015年5月至2016年5月进行肝硬化伴食管静脉曲张套扎术的87例患者,采用数字表法随机分为对照组(43例)和观察组(44例),对照组给予基础护理,而观察组进行心理干预、饮食干预、用药干预、出院指导等护理补充干预。观察并对比两组护理效果。 结果两组护理效果比较,(1)观察组患者再出血率为9.09%,较对照组的25.58%明显降低,差异有统计学意义(P<0.05);(2)对两组患者术后并发症随访发现,观察组患者术后并发率为11.36%,较对照组患者术后并发率的30.23%明显降低,差异有统计学意义(P<0.05);(3)对照组患者满意度为76.74%,观察组患者的满意度95.45%,差异有统计学意义(P<0.05)。 结论通过精心细致的护理补充干预可明显降低食管静脉曲张套扎术后再出血的发生率,减少术后并发症的发生,显著提高患者满意度,从而提高护理服务质量。     

Therapy and prevention of hemorrhage from esophageal varices

Management of variceal hemorrhage includes emergency treatment of bleeding esophageal varices and prophylactic treatment for the prevention of first bleeding or rebleeding. Endoscopic injection sclerotherapy appears to be the most effective therapeutic option to control acute variceal hemorrhage. When sclerotherapy fails or cannot be performed a Sengstaken-Blakemore tube can be used. Supportive treatment is provided by vasodilator or vasoconstrictor therapy. At present, operative treatment modalities such as portosystemic shunts or esophageal transection are secondary to sclerotherapy or balloon tamponade. The probability of recurrent variceal hemorrhage after a first bleeding is 70%. This necessitates preventive measures such as endoscopic sclerotherapy, beta-blockade, or surgical procedures. Meta-analysis of randomised controlled trials indicates that sclerotherapy appears to reduce the number of episodes of recurrent variceal hemorrhage better than other prophylactic treatments and to improve survival. Chronic sclerotherapy may be the procedure of first choice in patients with good liver function when elective shunt surgery is provided for those who have recurrent bleeding despite sclerotherapy. The role of beta-blockade in the prevention of recurrent bleeding remains to be clearly defined. Prevention of first esophageal bleeding by invasive treatment modalities could reasonably only be performed in patients with high bleeding risk, which, however, cannot be defined accurately at present. The use of beta-blockers in the prevention of first variceal hemorrhage should be restricted to clinical trials.     

Results of modified Sugiura operation in variceal bleeding in cirrhotic and noncirrhotic patients

BACKGROUND/AIMS: Esophageal variceal bleeding is a major complication of portal hypertension and the optimal therapeutic modality for each individual patient differs. We reviewed the results of modified Sugiura procedure in patients with variceal bleeding of esophagus. METHODOLOGY: We retrospectively reviewed the charts of 13 patients who were subjected to modified Sugiura procedure (transabdominal esophagogastric devascularization + esophageal stapled transection + splenectomy) for bleeding esophageal varices between 1996 and 2001. Three patients disappeared from routine follow-up and were excluded from the study. Survival, rebleeding and encephalopathy were evaluated. RESULTS: The mean age was 46 (18-56). The etiology of portal hypertension was cirrhosis of liver in six (60%) and portal vein thrombosis in four (40%). One patient had Child-Pugh's Class A, two had Class B and three had Class C cirrhosis. Previous variceal bleeding were confirmed by endoscopy in all patients who had recurrent variceal bleeding despite treatment with beta-blockers (three patients) or endoscopic sclerotherapy +/- band ligation (seven patients). Two were subjected to emergency surgery while the remaining eight were operated on electively. No postoperative mortality was seen. The bleeders were stopped immediately in the emergent cases. During a mean follow-up of 27 (4-53) months, one (10%) patient suffered from encephalopathy and one (10%) from rebleeding at 20th and 28th months after the operation respectively. Three (30%) patients with Child C cirrhosis died due to bleeding (one) and hepatic failure (two) at 4, 25, and 28 months after the surgery. The prognoses of other patients are well at the present time. CONCLUSIONS: In our small number of patients, modified Sugiura procedure was found to be a safe and effective procedure for urgent and long-term control of bleeding varices in patients with portal hypertension due to cirrhosis and noncirrhotic etiology. The outcomes are encouraging in noncirrhotic patients and cirrhotic patients with good liver functions.     

Long-term follow-up of patients with liver cirrhosis after endoscopic esophageal varices ligation therapy: comparison with ethanol injection therapy

BACKGROUND/AIMS: Esophageal variceal hemorrhage is the most dreaded complication of liver disease. Prevention or emergency therapy of bleeding is important. METHODOLOGY: A group of 217 patients underwent endoscopic esophageal variceal therapy including endoscopic ethanol injection, endoscopic esophageal variceal ligation, or a combination of the two. RESULTS: Esophageal varices were eradicated by endoscopic esophageal variceal ligation with the least sessions required, and associated complications with endoscopic esophageal variceal ligation therapy were lower than with the other two approaches. However, the cumulative recurrence-free period of esophageal varices was significantly higher after endoscopic ethanol injection than after endoscopic esophageal variceal ligation and in some cases F3 varices were observed post-endoscopic esophageal variceal ligation hemorrhage. A combined endoscopic esophageal variceal ligation and endoscopic ethanol injection therapy had no advantage with respect to cumulative recurrence-free rate, session number, or complication frequency, relative to either therapy alone. CONCLUSIONS: While the combined observations indicate that endoscopic esophageal variceal ligation is safe and simple, we should consider additional therapy to achieve complete mucosal fibrosis of the esophagus after endoscopic esophageal variceal ligation.