脾切除联合内镜曲张静脉套扎术与Hassab术的对比研究

A combination splenectomy and endoscopic varices ligation in comparison with Hassab procedure in the treatment of portal hypertension

目的对比研究脾切除联合内镜食管曲张静脉套扎术与Hassab术治疗门静脉高压症的临床疗效及其对机体的病理生理影响。方法将1999年1月-2002年6月收治的103例肝硬化门静脉高压症患者随机分为A、B两组。A组53例,行脾切除联合内镜食管曲张静脉套扎术;B组50例,行经典的Hassab术(即脾切除联合贲门周围血管离断术)。比较两组门静脉血流动力学、门静脉血栓发生率、胃动力、食管静脉曲张分级、门静脉高压性胃病分级、并发症、手术死亡率、复发出血率。结果两组术后自由门静脉压、门静脉血流速度及血流量均比术前下降(P<0．01),但两组之间差异无统计学意义(P>0．05)。术后2-4周以彩色B超动态监测门静脉血栓发生情况,A组发生血栓7例(13％),B组14例(28％)(P<0．05)。A组术后2周的餐后胃动力分级优于B组(P<0．05)。A组术后发生并发症17例(32％),B组30例(61％)(P<0．01)。两组均无手术死亡。对患者进行随访24．5-64个月(平均45个月),A、B组获得随访者各为42、38例,A组食管曲张静脉复发率为10％,复发出血3例(7％);B组复发率为12%,复发出血2例(5％)(P>0．01);A组门静脉高压性胃病分级与术前比较无差异,B组比术前加重(P<0．01)。结论脾切除联合内镜食管曲张静脉套扎术的临床疗效与Hassab术相当,但对患者的生理干扰较小,术后并发症较少,尤其是门静脉血栓的发生率较低,而且操作较简单,创伤较小,有一定的实用价值。

Objective To evaluate the effect of combination splenectomy and endoscopic varices ligation in comparison with Hassab procedure in the treatment of portal hypertension. A prospective, controlled study was carried out on Splenectomy with EVL in comparision with portoazygous disconnection the Hassab procedure to assess whether SEVL can achieve better results in the treatment of portal hypertension. Methods From Jan 1999 to June 2002, 103 cirrhotic patients with portal hypertension were admitted. These patients were randomized into two groups. Group A were treated by splenectomy combined with EVL（53 cases）, and group B were treated with Hassab procedure（50 cases）. Results In both groups, there was a significant postoperative decrease in free portal pressure, the velocity and volume of portal flow （ all P 〈 0. 01 ）, but the difference of individual parameters between the two groups was not significant （ P 〉 0. 05）. Portal vein thrombosis developed in 7 cases （ 13% ） in group A, and in 14 cases （28%） in group B, P 〈0. 05. Postoperative complications developed in 17 cases （32%） in group A and in 30 cases （61%） in group B, P 〈 0.01. There was no mortality postoperatively. Postoperative variceal recurrence was 10. 2% for group A and 12% for group B. Rebleeding was noted in 3 cases （7%） of group A and 2 cases （5%） of group B. Portal hypertensive gastropathy remained unchanged in group A and exacerbated in group B （P 〈0. 05）. Conclusion Splenectomy with EVL is an effective procedure for control of variceal bleeding in portal hypertension, compared with Hassab procedure, causing less injury and less impediment on splanchnic hemodynamics and physiology.