基于术中自由门静脉压测定的脾切除加选择性断流术的临床分析  

Clinical analysis of splenectomy and selective devascularization based on intra-operative free portal pressure

作　　者：曹技磊 卢实春[2] 曾道炳[1] 赖威[3] 林栋栋[1] 武聚山[1] 郭庆良[1] 王孟龙[1] 李宁[1] 

机构地区：[1]首都医科大学附属北京佑安医院普外中心,100069 [2]解放军总医院肝胆外科 [3]成都市第一人民医院普外科

出　　处：《中华肝胆外科杂志》2014年第9期648-651,共4页Chinese Journal of Hepatobiliary Surgery

基　　金：首都卫生发展科研专项基金（首发2011-2018-03）;北京市卫生系统高层次卫生技术人才培养计划资助（2011-2-18）

摘　　要：目的 分析门静脉测压指导下脾切除加选择性断流对肝硬化门脉高压症的近远期疗效.方法 回顾性分析2003年6月至2013年9月于我科因门静脉高压症行手术治疗且随访资料完整的304例患者的临床资料.按手术方式将患者分为门静脉测压指导下选择性断流组（n=71）和经典断流组（n =233）.比较两组术后再出血率、各级门静脉血栓形成率以及胃排空延迟等并发症的发生率,观察全组患者手术前后肝功能相关指标的变化.结果 全组患者脾切除断流术后1、3、5、10年生存率分别为95％、92％、85％、77％,肝脏中位生存期为93个月.与术前比较,术后患者肝功能Child-Pugh评分明显改善（6.41 ±1.26比6.21 ±1.04;P＜0.05）.门脉压指导下选择性断流组与经典断流组相比再出血率（5.6％比24.1％）、Yeld分级中Ⅰ/Ⅱ级门静脉血栓形成率（19.7％比33.9％）、胃排空延迟发生率（0比5.6％）均较低,差异有统计学意义（P＜0.05）;Ⅲ/Ⅳ级门静脉血栓形成率（2.8％比3.4％,P＞0.05）差异无统计学意义.两组切脾术后自由门静脉压（FPP）均降明显降低（P＜0.05）,但选择性断流组降压幅度更大[（10.06±4.34） cmH2O（1 cmH2O=0.098 kPa）比（8.26±4.82） cmH2O,P＜0.01].选择性断流组手术时间、术中出血量均少于经典断流组（P＜0.01）.结论 脾切除加断流术对于门静脉高压患者具有明确的降低FPP、改善肝功能的作用.门静脉测压指导下的选择性断流具有更理想的手术安全性及临床预后.Objective To investigate the short-term and long-term outcomes in patients with portal hypertension who underwent splenectomy and selective gastroesophageal devascularization based on intraoperative free portal pressure （FPP）.Methods The clinical data of 304 patients from June 2003 to September 2013 were retrospectively analyzed.71 patients underwent splenectomy and selective gastroesophageal devascularzation （group A） and 233 patients received splenectomy and classical gastroesophageal devascularzation （group B）.The alteration of FPP,liver function,operation time,volume of blood loss and postoperative complications were compared between the two groups.Results The overall 1-,3-,5-and 10-year accumulative survival rates in all the patients were 95%,92%,85% and 77% respectively.Median survival of the liver was 93 months.The Child-Pugh score （6.21 ± 1.04 vs 6.41 ± 1.26; P 〈 0.05） significantly decreased postoperatively in two weeks in all the patients.The postoperative complications including rebleeding rate （5.6% vs24.1%,P〈0.05）,grade Ⅰ and Ⅱ portal vein thrombosis （19.7% vs 33.9%,P〈0.05） and delayed gastric function （0 vs 5.6%,P 〈0.05） were significantly different between group A and group B.There were no significant difference between grade Ⅲ and Ⅳ portal vein thrombosis （2.8% vs 3.4%,P 〉 0.05）.The FPP decreased significantly in both groups,but it decreased more in group A than group B [（10.06 ±4.34）cmH2O（1 cmH2O =0.098 kPa） vs （8.26 ±4.82）cmH2O,P 〈0.01].Moreover,the operation time and the volume of blood loss in group A were significantly less than those in group B.Conclusions Cirrhotic patients with portal hypertension benefited from splenectomy and gastroesophageal devascularization.Selective gastroesophageal devascularization was more safe and effective in patients with portal hypertension.

关 键 词：门静脉高压症 脾切除术 断流术 再出血率 

分 类 号：R657.6[医药卫生—外科学]