术中门静脉压力动态测定在门静脉高压症术式选择中的作用

Function of portal pressure during operation on the choice of surgical approaches in portal hypertension

目的分析断流手术和脾切除脾肾静脉分流加断流联合手术后自由门静脉压（FPP）与术后再出血以及肝性脑病的关系，探讨术中FPP动态变化对术式选择的意义。方法回顾性分析2001年1月至2007年12月接受贲门周围血管离断术和贲门周围血管离断加脾肾静脉分流术（联合组）患者170例的临床资料。断流组患者断流术后FPP值≥22mmHg（1mmHg=0．133kPa）为高压组（60例），〈22mmHg为低压组（43例），联合组共67例。三组患者术前Child-Pugh评分和FPP之间差异无统计学意义（P〉0．05）。比较三组患者术中不同时间点FPP变化、以及三组患者术后再出血和肝性脑病发生率。结果高压组、低压组和联合组术后FPP值分别为（27．1±1．9）mmHg、（20．8±1．8）mmHg和（21．5±2．2）mmHg，再出血率分别为％、4．6％和4．5％。再出血率在高压组显著高于低压组和联合组（P〈0．05）。术后肝性脑病发生率联合组（10．4％）虽然高于低压组（7．0％）和高压组（3．3％），但差异无统计学意义（P〉0．05）。结论脾切除断流术后FPP值可以作为选择手术方式的依据，如FPP值≥22mmHg应加行脾肾静脉分流术。

Objective To investigate the relationship between perioperative free portal pressure （FPP） after devasculafization or spleno-renal shunt operation added devaseularization and rebleeding or encephalopathy in patients with portal hypertension, and evaluate the relationship between dynamic changes of FPP and surgical approaches. Methods The clinical data of 170 patients with portal hypertension receiving devascularization or devascularization with spleno-renal shunt operation （ combination group） from January 2001 to December 2007 were retrospectively analyzed. All patients were divided into three groups： low pressure group [ L group, after devasculafization FPP ≤22 mm Hg （ 1 mm Hg = 0. 133 kPa）, n = 431, high pressure group （ H group, FPP 〉 22 mm Hg, n = 60） and combination group （ C group, n = 47 ）. There was no significant difference in preoperative Child-Pugh score and pre-operation FPP （ P 〉 0.05 ） among the three groups. Perioperative FPP, morbidity of rehleeding and encephalopathy were compared with each other. Results The values of postoperative FPP were （ 27. 1±1.9 ）mm Hg, （ 20. 8±1.8 ） mm Hg and （ 21.5±2.2） mm Hg among the H group ,L group and C group respectively. The rebleeding rates were 21.7% , 4. 6% and 4. 5% among the three groups respectively. All the values in H group were higher than those in L group and C group remarkably. The encephalopathy rate in C group （ 10. 4% ） was higher than that in L group （7. 0% ） or H group （3.3%）, but there were no statistical significance （ P 〉 0.05 ）. Conclusions FPP after lienectomy and devascularization may be a gist of choice of surgical approaches in portal hypertension. The spleno-renal shunt operation should be performed in the patients when FPP is over 22 mm Hg after devascularization.