同期肝切除联合脾切除在肝癌合并门静脉高压患者中的应用探讨

目的探讨肝癌合并门静脉高压伴食管静脉曲张破裂出血的患者同期行肝癌切除和脾切除的安全性及可行性。 方法回顾性分析2002年1月至2018年1月期间42例肝癌合并门静脉高压伴食管静脉曲张破裂出血行肝脾联合切除患者的临床资料。记录手术时间、术中出血量及术后并发症发生例数。采用门诊复查或电话随访方式随访,随访截至时间为2022年1月。 结果开腹联合切除33例（78.6%）,腹腔镜联合切除9例（21.4%）。其中8例行同期肝切除合并脾切除（19.0%）,34例行同期肝切除合并脾切除同时加做贲门周围血管离断（81.0%）。术中出血量（771.4±500.2）ml,术中均未行肝门阻断;手术时间（5.6±2.6）h;42例患者术后病理学检查均证实为肝细胞癌。术后无围手术期临床死亡病例;术后3~6 d均恢复正常饮食。术后发生门脉系统血栓形成最为常见,共计出现32例（76.2%）,单侧或者双侧胸腔积液21例（50.0%）,肝周或者脾窝脓肿形成3例（7.1%）,胆瘘2例（4.8%）,严重门脉及脾静脉血栓形成致持续高胆红素血症1例（2.4%）,后介入行肠系膜上动脉置管行肝素钠及尿激酶溶栓后好转。术后随访<5个月的3例（7.1%）,超过1年的患者39例（92.9%）,超过5年的患者9例（21.0%）。其中17例肿瘤复发或转移,并行进一步治疗（40.5%）;13例复查胃镜出现不同程度食管静脉曲张（31.0%）。 结论对于肝癌合并门静脉高压伴脾功能亢进及食管静脉曲张破裂出血的患者,可选择行肝脾联合切除,具有一定的安全性和可行性。

Application of simultaneous hepatectomy combined with splenectomy in hepatocellular carcinoma patients with portal hypertension

ObjectiveTo investigate the safety and feasibility of hepatectomy and splenectomy in patients with hepatocellular carcinoma complicated with portal hypertension and esophageal varices rupture and hemorrhage. MethodsFrom January 2002 to January 2018,the clinical data of 42 patients with hepatocellular carcinoma complicated with portal hypertension and esophageal varices rupture and hemorrhage who underwent hepatosplenectomy were retrospectively analyzed. The operation time,intraoperative blood loss and postoperative complications were recorded. The patients were followed up by outpatient review or telephone follow-up until January 2022. Results33 cases（78.6%）underwent laparotomy and 9 cases（21.4%）underwent laparoscopy. Among them,8 patients underwent simultaneous hepatectomy combined with splenectomy（19.0%）,and 34 patients underwent simultaneous hepatectomy combined with splenectomy combined with pericardial devascularization（81.0%）. The intraoperative blood loss was（771.4±500.2）ml. No hilar block was performed during the operation. The operation time was（5.6±2.6）hours. All 42 patients were confirmed to be hepatocellular carcinoma by postoperative pathological examination. There was no perioperative clinical death. All patients returned to normal diet 3 to 6 days after operation. Postoperative portal vein thrombosis was the most common occurrence,including 32 cases（76.2%）,21 cases（50.0%）of unilateral or bilateral pleural effusion,3 cases（7.1%）of perihepatic or splenic fossa abscess,2 cases（4.8%）of bile leakage,1 case（2.4%）of persistent hyperbilirubinemia caused by severe portal vein and splenic vein thrombosis. After intervention,superior mesenteric artery catheterization and thrombolysis with heparin sodium and urokinase improved. Three patients（7.1%）were followed up for less than 5 months,39 patients（92.9%）were followed up for more than 1 year,and 9 patients（21.0%）were followed up for more than 5 years. Among them,17 cases had tumor recurrence or metastasis and received further treatment（40.5%）. 13 cases（31.0%）had esophageal varices of varying degrees. ConclusionFor patients with hepatocellular carcinoma complicated with portal hypertension,hypersplenism and esophageal varices rupture and bleeding,combined hepatosplenectomy can be selected,which has certain safety and feasibility.