脾大部切除术与脾完全切除术比较治疗肝硬化门脉高压症的系统评价

Subtotal Splenectomy versus Total Splenectomy for Hepatic Cirrhosis and Portal Hypertension:A Systematic Review

目的系统评价脾大部切除联合断流术和脾完全切除联合断流术治疗肝硬化门脉高压症的疗效。方法计算机检索Cochrane图书馆(2008年第2期);MEDLINE(1966.1～2008.8);EMbase(1966.1～2008.8);CBM(1978.1～2008.8);VIP(1989.1～2008.8);CNKI(1994.1～2008.8)。手工检索相关杂志及会议论文集中未发表的文献。结果纳入3个随机对照试验,共136例患者,试验组68例,对照组68例。2个研究的合并分析结果表明,脾大部切除术后患者外周血小板水平提高更低[WMD=–39.27,95%CI(–62.57,–15.97)]。另2个研究的合并分析结果表明,脾大部切除术后患者血清Tuftsin水平更高[WMD=165.28,95%CI(159.36,171.21)]。2个研究的合并结果显示,两组患者血清IgM水平差异无统计学意义[WMD=0.52,95%CI(–0.17,1.21)]。1个研究发现脾大部切除术可提高外周白细胞水平[WMD=–0.93,95%CI(–1.52,–0.34)]。1个研究显示两组血清IgA水平差异无统计学意义[WMD=0.05,95%CI(–0.02,0.12)]。另1个研究表明脾完全切除组患者术后均发热天数长于脾大部切除组,两组5年生存率差异有统计学意义(P<0.05)。结论脾大部分切除术后患者能维持免疫系统的储备功能,有助于保持抗感染能力。鉴于本系统评价纳入的研究太少,质量均不高,每个研究纳入病例不多,测量指标不全面,随访时间不长,影响了本系统评价的论证强度及全面性。因此尚需开展更多高质量研究。

Objective To evaluate the efficacy of the subtotal splenectomy versus total splenectomy with gastroesophageal devascularization for patients of hepatic cirrhosis and portal hypertension. Methods We searched the Cochrane Library （Issue 2, 2008）, MEDLINE （1966 to August, 2008）, EMbase （1966 to August, 2008）, the China Biological Medicine Database （1978 to August, 2008）, Chinese Sci-tech Periodical Full-text Database （1989 to August, 2008） and Chinese Periodical Full-text Database （1994 to August, 2008）, as well as hand-searched several related journals and conference proceedings for the randomized controlled trials involving the comparison of the efficacy of the subtotal splenectomy with the total splenectomy for the patients of the hepatic cirrhosis and portal hypertension. Results Three studies involving 136 patients were identified. The results of two studies indicated that both of the subtotal splenectomy increased less the peripheral platelet count and there was a statistically significant difference between the two groups [WMD=-39.27, 95%CI （-62.57, -15.97）]. Two studies indicated that the serum tuftsin level was increased significantly after the subtotal splenectomy [WMD= 165.28, 95%CI （159.36, 171.21）]. One study indicated that both of the subtotal splenectomy and total splenectomy with gastroesophageal devascularization increased the peripheral white blood cell count and there was statistical difference between the two groups [WMD= -0.93, 95%CI （-1.52, -0.34）]. There was no statistical difference in serum IgA level between the two groups. One study indicated the average fever time after the total splenectomy was longer than the subtotal splenectomy; there was statistical differences in 5 years survival rate between the two groups （P〈0.05）. Conclusions After the subtotal splenectomy the hypersplenism of patients suffered from hepatic cirrhosis and portal hypertension was corrected obviously and the blood cells were increased smoothly so that high blood viscosity was prevented and occurrence of the thrombotic diseases was decreased. And the immune system reserve functions of the patients with hepatic cirrhosis and portal hypertension were maintained. More randomized controlled trials, with large sample sizes, may lead to more accurate results.