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。

Clinical Significance of Several Improvements in the Selective Pericardial Devascularization for the Treatment of Portal Hypertension

Objective To evaluate the rational effects of several improvements in the selective pericardial devascularization for the treatment of portal hypertension. Methods 11 cases of portal hypertension were enrolled. MRA or three-dimensional portograpby with 64-slice helical CT were performed to display portal venous system and collateral circulation stereoscopically, which was contributive to the etiological diagnosis and the preoperative evaluation. The improvement of the operative approaches was called ＂3-closing dissecting technique＂, which to dissect the tissues close to spleen, esophageal and gastric area during shunt. An anticoagnlation tube was inserted into the splenic vein branch by which heparin was infused after operation. Results There was no delayed gastric emptying or portal vein thrombosis after operation. But 2 occurred left subphrenic hydrops, 1 of pleural effusion, 1 of refractory ascites, and 3 of continue low-grade fever. All the complications were cured by expectant treatments. 10 patients were followed up for 2 months to 3 years, in whom 2 died of brain hemorrhage and liver function failure respectively. It showed the phlebeurysma disappeared in the inferior segment of the esophagus in 6 cases by upper gastrointestinal tract photography and in 2 by gastroscopy in 3 months after operation. But 2 cases showed mild phlebeurysma in the inferior segment of the esophagus in 9 patients receiving upper gastrointestinal tract photography during 13 to 35months after the operation. The incidence of rebleeding and hepatic encephalopathy was 0. Conclusion The improvements of the selective pericardial devascularization are safe and effective with no increasing rate of the postoperative complication, nor rebleeding.