脾肾静脉分流联合断流术的临床疗效及对门静脉系统血流动力学的影响

目的评价近端脾肾静脉分流加门奇断流联合手术和门奇断流术的临床疗效及对门静脉系统血流动力学的影响。方法回顾性总结近8年采用脾肾分流加门奇断流联合手术和门奇断流术治疗门静脉高压症245例,于术前一周和术后2周应用核磁共振血管造影测量门静脉、脾静脉和肠系膜上静脉的直径,流速和流量,并于术中动态测量门静脉压力。结果联合手术组术后较术前门静脉血流量下降,肠系膜上静脉流量增加,差异有统计学意义(P<0.05),门静脉直径和自由门静脉压下降差异有统计学意义(P<0.01)。联合手术组与断流组相比,门静脉血流量的减少差异没有统计学意义,而自由门静脉压的下降差异有统计学意义(P<0.01)。联合手术组术后再出血率明显低于断流组,而肝功能和脑病发生率两组间差异无统计学意义。结论联合手术可结合断流和分流手术的优点,既明显降低出血率又不增加脑病发生,应成为治疗门静脉高压症合并出血的首选术式。

Clinical effect of spleno-renal shunt combined with pericardial devascularization and its influence on hemodynamics of portal venous system

Objective To investigate the clinical effects of pericardial devascularization (PCDV) and proximal spleno-renal shunt (PSRS) combined with PCDV and evaluate respectively their effects on hemodynamics of portal venous system. Methods A retrospective analysis was carried out in 245 cases with portal hypertension treated with PCDV (PCDV group) or PSRS plus PCDV (combination group). The diameter, blood flow velocity and blood flow of portal vein, splenic vein and superior mesenteric vein were measured by magnetic resonance angiograph at 1 week preoperatively and at 2 week postoperatively. Free portal pressure (FPP) was continuously determined during operation. Results In combination group, the blood flow of portal vein decreased and that of superior mesenteric vein increased (P<0.05), but the diameter of portal vein and FPP decreased very significantly (P<0.01) compared with the preoperative data. There was no significant difference upon decrease of blood flow of portal vein but very significant difference upon decrease of FPP between combination group and PCDV group (P<0.01). Postoperative incidence rate of rebleeding in combination group was significantly lower than that in PCDV group (P<0.01). While there was no significant difference upon liver function and incidence rate of postoperative hepatic encephalopathy between both groups. Conclusions PSRS plus PCDV should be the treatment of choice for treatment of portal hypertension combined with hemorrhage because it integrates advantages of shunt and devascularization, significantly decreases incidence rate of rebleeding and avoids increase of hepatic encephalopathy.