贲门周围血管离断优先策略在腹腔镜断流术治疗门静脉高压症的应用评价

目的探讨先离断贲门周围血管后切除脾脏的腹腔镜断流术治疗门静脉高压症(portal hypertension,PHT)的效果。方法选择2013年1月~2018年12月151例腹腔镜脾切除贲门周围血管离断术(laparoscopic splenectomy and pericardial devascularization,LSPD),以2015年8月调整腹腔镜断流术手术策略为界,分为2组:A组70例,腹腔镜下先切脾后断流手术;B组81例,腹腔镜下先断流后切脾手术。比较2组资料近期临床疗效和住院费用。结果151例均顺利完成手术,无中转开腹手术。所有患者术后均发热,对症处理后均消失。无胃肠漏、胰漏、大出血并发症发生。2组住院期间各1例死亡:A组1例术后第6天猝死,考虑为肺栓塞所致;B组1例术中胃内大出血,术后第3天多器官衰竭死亡。与A组相比,B组手术时间明显缩短(261.4±46.1)min vs.(180.8±61.4)min,t=2.558,P=0.019],术中出血量明显减少中位数:480(120~2000)ml vs.200(80~400)ml,Z=-5.376,P=0.000]。2组患者总住院时间、术后住院时间、引流时间、住院总费用差异无显著性(P>0.05)。随访术后1年,2组各有1例发生便血,门静脉系统血栓发生率差异无显著性A组28.9%(20/69),B组23.8%(19/80),χ^2=0.526,P=0.468]。结论贲门周围血管离断优先的腹腔镜断流术治疗PHT疗效满意。

Evaluation of Priority Strategy of Transecting Esophagogastric Vessels in Laparoscopic Pericardial Devascularization for the Treatment of Portal Hypertension

Objective To explore the effect of laparoscopic devascularization of the spleen after the pericardial blood vessels transection in the treatment of portal hypertension(PHT).Methods From January 2013 to December 2018,151 cases of laparoscopic splenectomy and pericardial devascularization(LSPD)were selected and divided into two groups(taking the adjustment of operation strategy of laparoscopic disconnection in August 2015 as time node):group A(70 cases)underwent laparoscopic splenectomy before devascularization;group B(81 cases)underwent laparoscopic splenectomy after devascularization.The short-term clinical efficacy and hospitalization cost of the two groups were compared.Results The operations of laparoscopic devascularization were successfully finished in all the 151 cases without conversion to open surgery.All the patients had fever of different degrees after operation and disappeared after symptomatic treatment.No complications such as gastrointestinal leakage,pancreatic leakage or massive hemorrhage occurred.There was one death case respectively in the 2 groups during hospitalization.The case in the group A died suddenly on the 6th day after operation,which was caused by pulmonary embolism.The one in the group B with intraoperative massive intragastric hemorrhage died of multiple organ failure on the 3rd day after operation.Compared with the group A,less operation time(261.4±46.1)min vs.(180.8±61.4)min,t=2.558,P=0.019]and less intraoperative bleeding lossmedian:480(120-2000)ml vs.200(80-400)ml,Z=-5.376,P=0.000]were seen in the group B.There were no significant differences in the total hospitalization time,the postoperative stay,the indwelling time and the total cost of hospitalization between the two groups(P>0.05).The two groups were followed up for 1 year.One case of hematochezia was found in each group.No significant difference was seen between the two groups in the incidence of portal vein thrombosisgroup A:28.9%(20/69),group B:23.8%(19/80),χ^2=0.526,P=0.468].Conclusion Pericardial transection of esophagogastric vessels prior to laparoscopic devascularization for PHT is effective.