小口径人工血管架桥门体分流联合贲门周围血管离断术治疗门静脉高压症上消化道出血

目的 探讨小口径人工血管(直径0.8 cm)门体静脉架桥联合贲门周围血管离断术在门静脉高压症(PHT)合并上消化道出血治疗中的应用价值.方法 对38例PHT合并上消化道出血患者采用小口径人工血管脾-腔架桥(14例)、肠-腔架桥(24例)联合贲门周围血管离断术治疗.结果 术后患者自由门静脉压力平均下降(6.6±1.2)cm H2O,手术前后肝功能相比差异无统计学意义(P>0.05).脾-腔架桥组术后外周血血小板和白细胞计数恢复正常(均P<0.05).手术死亡率为3%.术后并发症有发热4例,顽固性腹水和乳糜腹水各1例,肝性脑病1例,腹腔感染1例,应激性溃疡1例.除1例腹腔感染患者死亡外,其余经保守治疗后均痊愈.对35例进行了6个月至3年的随访,消化道出血复发2例,死亡2例,总有效率为89%.1年和3年人工血管通畅率分别为80%和75%.25例患者于术后6个月行纤维胃镜检查,食管胃底静脉曲张基本消失或减轻.结论 小口径人工血管架桥门体分流联合贲门周围血管离断术治疗PHT合并上消化道出血可明显降低门静脉压力,有效控制上消化道出血,肝性脑病发生率低.脾-腔架桥术可同时消除患者脾脏功能亢进.

Small diameter graft shunts combined with pericardial devascularization for the treatment of bleeding esophagogastric varices

Objective To study the effect of small diameter graft (0.8 cm) splenocaval or mesocaval shunts combined with pericardial devascularization in the treatment of portal hypertensive variceal bleeding. Methods Splenocaval shunts were performed in 14 patients and mesocaval shunts were done in 24 patients, in combination with pericardial devascularization. Results The average decrease of free portal pressure was 6.6±1.2 cm. There was no significant changes in liver function postoperatively (P>0.05). Platelet counts and leukocyte counts were back to normal in splenocaval shunt patients postoperatively (P< 0.05). Operative mortality was 3%. Pyrexia developed in 4 patients, intractable ascites in 1 patient, chylons ascites in 1 patient, hepatic encephalopathy in 1 patient, intraabdominal infection in 1 patient and stress ulceration in 1 patient. All patients recovered after expectant treatment except one who died from severe intraabdominal infection. 35 patients received follow-up between 6 months and 3 years, total effective rate was 89%, 2 patients died from recurrent variceal bleeding, the shunt potency rate was 80% in 1 year and 75% in 3 years. Esophagogastric varices disappeared or alleviated as shown by endoscopy in 25 patients on 6 months postoperatively. Conclusions Small diameter portosystemic graft shunts combined with poricardial devascularization is an effective therapy for bleeding esophagogastric varices with a low rate of hepatic encephalopathy. Splenocaval shunt alleviates hypersplenism concurrently.