肝硬变门静脉高压症脾切除对免疫功能的影响

目的:探讨门静脉高压症患者切除脾脏时免疫功能的影响。方法:采集126例门静脉高压症患者的肝素防凝血,正常对照组30例,利用Epics-XL型流式细胞仪分析测定T淋巴细胞亚群。结果:门静脉高压症患者较正常人细胞免疫功能明显降低,CD3,CD4,CD4/CD8的比值均降低,有非常显著意义(P<0.001)。保脾组手术后CD3值较手术前明显升高(P<0.05)。保脾组与切脾组手术后CD3值有明显差别(P<0.02)。保睥和切脾手术前后的体液免疫指标无明显差别。结论:门静脉高压症的保脾手术可维持机体较高的细胞免疫功能,但对体液免疫无意义。     

Hereditary spherocytosis associated with protein band 3 defect in a Swiss kindred

A kindred with hereditary spherocytosis, in which 10 individuals were affected, was investigated. Gel electrophoresis of membrane proteins revealed a protein band 3 defect (densitometric reduction 14·4±7·0%). The erythrocyte morphology of unsplenectomized patients showed so-called pincered erythrocytes (about 1%), which were not present in the five splenectomized patients. Splenectomy also reduced anisocytosis and all parameters of haemolysis, while haemoglobin increased. The osmotic resistance was reduced in patients with protein band 3 deficiency. Erythrocyte filterability through 3 μm pores was decreased. A significant correlation was found between osmotic resistance and filterability. The membrane elastic modulus of erythrocytes was not affected. These results on structural and functional properties of protein band 3 deficient erythrocytes may contribute to a better understanding of this newly discovered form of hereditary spherocytosis.     

Aggressive NK cell leukaemia after splenectomy: association with CD95-resistant memory T-cell proliferation and recalcitrant clinical course of haemophagocytic syndrome

We describe a 44-yr-old Japanese woman with persistent polyclonal T-cell proliferation and recalcitrant clinical course of haemophagocytic syndrome (HPS). T cells bearing αβ T-cell receptors (TCR) expressed increased amounts of CD95 and of CD45RO, which are phenotypically memory T cells. The TCR repertoire was broad and diverse. Regardless of CD95 expression, these cells were resistant to CD95-mediated apoptosis. Aggressive natural killer cell leukaemia (ANKL) without an association with Epstein–Barr virus was detected 1 month after therapeutic splenectomy that followed 3 yr of immunosuppressive therapy against HPS. The immunophenotype of these leukaemia cells was CD56, CD16^dim, CD7, CD45RA and they expressed some CD2, CD8 and HLA-DR. Moreover, hyperdiploid clones with complex chromosomal abnormalities were also detected. Latent NK-cell malignancy seemed to cause the CD95-resistant memory T-cell proliferation and splenectomy resulted in overt ANKL progression. There should be careful consideration of the risks versus benefits of splenectomy in HPS, in light of the possibility of fatal leukaemia/lymphoma progression.     

2种方法在治疗特发性血小板减少性紫癜长期疗效的对比

目的对比分析腹腔镜脾切除术与开腹脾切除术治疗特发性血小板减少性紫癜的围手术期结果及长期疗效。方法回顾性分析2011年1月至2015年1月该院肝胆外科124例特发性血小板减少性紫癜患者行脾切除术治疗(其中腹腔镜脾切除术68例,开腹脾切除术56例)的临床资料与随访结果。结果腹腔镜脾切除术组手术时间较开腹脾切除术组长,住院时间短,术中失血量少,术后疼痛轻,术后拔出引流管时间短,术后并发症发生率低。腹腔镜脾切除术组术后无下肢深静脉血栓(DVT)发生;开腹脾切除术组术后1例发生DVT。腹腔镜脾切除术组术后1例死于肺部感染。腹腔镜脾切除术组平均随访时间(33±11.8)个月,开腹脾切除术组平均随访时间(32±12.9)个月,腹腔镜脾切除术组中术后长期有效率为73.5%,开腹脾切除术组中术后长期有效率为76.7%(P0.05)。Kaplan-Meier分析显示,2组无复发生存率差异无统计学意义(P=0.697)。结论腹腔镜脾切除术治疗特发性血小板减少性紫癜的长期疗效与开腹脾切除术相当,但具有非常明显的微创优势。     

Laparoscopic splenectomy may be a superior supportive intervention for cirrhotic patients with hypersplenism

Background and Aims: To evaluate and compare laparoscopic splenectomy and partial splenic embolization as supportive intervention for cirrhotic patients with hypersplenism to overcome peripheral cytopenia before the initiation of and during interferon therapy or anticancer therapy for hepatocellular carcinoma. Methods: Between December 2000 and April 2008, 43 Japanese cirrhotic patients with hypersplenism underwent either laparoscopic splenectomy or partial splenic embolization as a supportive intervention to facilitate the initiation and completion of either interferon therapy or anticancer therapy for hepatocellular carcinoma. We reviewed the peri‐ and post‐intervention outcomes and details of the subsequent planned main therapies. For interferon therapy, the rate of completion, the rate of treatment cessation and virological responses were evaluated. Anti‐cancer therapies for hepatocellular carcinoma included liver resection, ablation therapy, intra‐arterial chemotherapy, and transarterial chemoembolization. Results: All patients tolerated the operations well with no significant complications. The platelet count was significantly higher in the laparoscopic splenectomy group than in the partial splenic embolization group at 1 and 2 weeks after the intervention. Interferon therapy was stopped in two patients in the partial splenic embolization group due to recurrent thrombocytopenia whereas all patients in the laparoscopic splenectomy group completed interferon therapy. The planned anticancer therapies were performed in all patients, and were completed in all patients without any problems or major complications. Conclusion: Laparoscopic splenectomy may be superior to partial splenic embolization as a supportive intervention for cirrhotic patients with hypersplenism. Future prospective, randomized controlled patient studies are required to confirm these findings.     

二级脾蒂分离法腹腔镜改良Sugiura手术治疗门静脉高压症

目的 探讨二级脾蒂分离法腹腔镜改良Sugiura手术治疗门静脉高压症的可行性和安全性.方法 对肝硬化门静脉高压症、脾肿大、睥功能亢进15例患者采用手助腹腔镜行改良Sugiura手术.结果 本组15例腹腔镜改良Sugiura手术,手术均获得成功,平均手术时间为256.5 min,平均出血量193 mL.术后全组均未发生严重并发症,无手术死亡,术后平均住院日为10.2d.结论 腹腔镜改良手术是安全可行的,降低了手术难度,有效地控制了出血,是值得选择的门静脉高压症的微创手术方式.     

门脉断流术联合脾脏切除术与双介入栓塞术治疗肝硬化门脉高压症疗效对比

目的对门脉断流术联合脾脏切除术与双介入栓塞术治疗肝硬化门脉高压症的疗效进行对比。方法分析122例肝硬化门脉高压症的住院患者,其中64例行门脉断流术联合脾脏切除术（手术组）,58例行双介入栓塞术（介入组）,观察两组患者治疗后1、12月与治疗前血细胞及肝功能变化;两种治疗术后不良反应发生率;术后随访观察1年期间患者死亡率与再出血率。结果两组患者治疗后肝功能均得以改善,白细胞血小板计数较术前明显升高（P〈0．05）,红细胞计数无明显变化;介入组患者不良反应发生率高于手术组;术后随访观察1年期间两组患者死亡率差异无统计学意义,但是介入组再出血率高于手术组（P〈0．05）。结论门脉断流术联合脾脏切除术治疗肝硬化门脉高压症安全有效,不良反应发生率低,而且远期疗效优于双介入栓塞术。     

对选择性贲门周围血管离断术的几点改进及其在门静脉高压症治疗中的应用价值

目的评价改良的选择性贲门周围血管离断术在门静脉高压症治疗中的效果。方法11例门静脉高压患者,运用磁共振血管造影及64层螺旋CT门静脉三维成像技术,立体显示门静脉属支及侧支循环,进行术前诊断及评估。术中采取紧贴脾、紧贴胃及紧贴食管分离的“三紧贴”原则,并对脾静脉插管,术后推注肝素预防门静脉系血栓形成。结果11例术后无胃排空障碍、门静脉系无血栓形成。术后左膈下积液2例、胸腔积液1例、顽固性腹水1例,持续低热3例,均经保守治疗后治愈。10例获随访,时间2个月～3年,死亡2例,分别死于脑出血和肝功能衰竭。术后3个月内6例行上消化道造影,2例行胃镜检查,均提示食管下段静脉曲张消失。术后13—35个月9例行上消化道造影,仅2例有轻度静脉曲张。均未见食管胃底曲张静脉复发出血,无肝性脑病。结论经改良后的选择性贲门周围血管离断术疗效满意,并不增加术后近期并发症的发生率和再出血率,是一种安全有效的术式。     

直线切割缝合器行二级脾蒂离断术在创伤性脾破裂脾切除术中的应用

目的创伤性脾破裂患者行脾切除术时,传统方法脾门的处理采用大块组织结扎,此法术后易发生一些常见并发症,如脾热、胰尾损伤、出血等。我院从2007年10月～2009年2月对部分创伤性脾破裂患者行脾切除时运用直线切割缝合器行二级脾蒂离断术,以探讨其对术后并发症及预后的影响。方法回顾性分析比较了传统组与对照组共112例纳入患者的临床资料,运用统计学方法获得有意义的结果。结果对照组中脾热、胰漏等术后发生率降低;血性引流物持续时间与住院时间缩短。结论直线切割缝合器行二级脾蒂离断术在创伤性脾破裂脾切除中的应用,可降低常见并发症发生率,改良预后,是一种值得推广的术式。     

Splenectomy protects experimental rats from cerebral damage after stroke due to anti-inflammatory effects

Background A recent study demonstrated that the inflammatory response accompanying necrotic brain injury played an important role in stroke. Thus, inhibition of this response may help to stop the expansion of infarcts. It has also been shown that the spleen, a major peripheral immune organ, plays a role in stroke-induced immune responses. This study aimed to establish rat models of middle cerebral artery occlusion (MCAO) and to investigate the effect of splenectomy and possible mechanisms in that rat models. Methods Infarct size in a stroke model was measured with the Nissl body staining method, numbers of inflammatory cells in ischemic regions were detected by immunofluorescence staining, and inflammatory factors were assayed by enzyme-linked immunosorbent assay and real-time PCR in brain homogenates and sera. The significance of differences was determined by one-way analysis of variance followed by the least significant difference post hoc test. Results Infarct size in the brain of rats that underwent splenectomies 2 weeks before permanent MCAO (34.93±3.23%) was over 50% smaller than those of rats subjected to the stroke surgery alone (74.33±2.36%, P < 0.001; 77.30±2.62%, P < 0.001). Lower numbers of T cells, neutrophils, and macrophages in brain tissue and lower levels of pro-inflammatory cytokines, such as IL-1β and TNF-α, were observed in rats that underwent splenectomies, compared with the two other groups, but splenectomized rats showed higher levels of the anti-inflammatory factor IL-10 in the brain. Conclusions The mechanism(s) by which splenectomy protects brain from damage induced by stroke may correlate with the decreased numbers of inflammatory cells and changes in inflammatory cytokines.