改良脾腔分流联合断流术治疗门静脉高压症的疗效分析

Combination modified splenocaval shunt and devascularization for the treatment of portal hypertension

目的探讨改良近端脾腔静脉分流联合责门周围血管离断术（分断流联合术）治疗门静脉高压症的疗效及其对门静脉血流动力学和肝储备功能的影响。方法回顾性分析我院1997—2007年接受分断流联合术治疗的门静脉高压症患者135例和断流术患者120例的临床资料。通过彩色多普勒超声测定门静脉血流量（PVF）及监测术中自由门静脉压（FPP），观察手术前后门静脉系统血流动力学的变化。采用吲哚氰绿排泄实验观察15min（R15）滞留率和肝有效血流量（FHF）的变化。结果联合组手术死亡率为2．2％，无近期出血病例，远期出血率为5．5％，肝性脑病发生率为6．4％，术后1、3、5、10年生存率分别为96．4％、90．0％、81．3％和62．5％；断流组手术死亡率为4．3％，近期出血率为3．3％，远期出血率为14．1％，肝性脑病发生率为5．4％，1、3、5、10年生存率分别为95．7％、86．7％、75．0％和57．1％。联合组术后FPP、PVF和FHF分别为（32．0±1．5）cmH2O、（880±260）ml／min和（430±180）ml／min，较术前均下降（P〈0．05）。R15为30％±4％，较术前明显增加（P〈0．01）；断流组术后FPP、PVF和FHF下降（P〈0．01），R15增加（P〈0．01）。与断流组比较，联合组术后FPP下降更为明显（P〈0．05），但PVF、FHF和R15之间相比差异均无统计学意义（P〉0．05）。结论改良脾腔静脉分流联合断流术的临床疗效满意，血流动力学改变合理，对肝储备功能影响较小，是治疗门静脉高压症的理想术式。

Objective To evaluate the effects, hemodynamics and hepatic functional reserve of a combined procedure of modified proximal splenoeaval shunt and pericardial devaseularization （ PCDV ） in the treatment of portal hypertension. Methods From 1997 to 2007, a total of 255 patients with cirrhotic portal hypertension received combined （135 eases） or PCDV procedure （120 cases, ） in our hospital. The clinical results were retrospectively analyzed. Changes of hemodynamics of the portal venous system were studied by Doppler color flow imaging and intraoperative free portal pressure （ FPP ） measurement. The hepatic functional reserve was evaluated by indocyanine green （ICG） retention ratio and functional hepatic flow （FHF）. Results Postoperative mortality was 2.2% in combined group and 4. 3% in PCDV group. The long term rebleeding rate was 5.5% as revealed by follow-up in combined group, which was significantly lower than that in PCDV group of 14. 1% （P 〈 0. 05 ）. The incidence of eneephalopathy was 6.4% and 5.4% in combined group and PCDV group respectively （P 〉 0. 05）. The 1-, 3-, 5- and 10 year-survival rates were 96.4% ,90.0% ,81.3% and 62. 5% in combined group and 95.7% ,86. 7% ,75.0% ,57. 1% in PCDV group. In combined group, the FPP,PVF and FHF were （32.0 ± 1.5 ）cm H2O, （880 ± 260 ） ml/min and （430 ± 180） ml/min respectively, a significant decrease when compared with preoperative parameters （P 〈 0. 05 ）, while R15 （30% ± 4% ） increased （ P 〈 0. 01 ）. The similar results were observed in PCDV group postoperatively （P 〈 0.05）. Compared to PCDV group, the decrease of FPP in combined group was more significant （P 〈 0. 05）, but the PVF, FHF and R15 were not significantly different （P 〉 0. 05 ）. Conclusions The combined procedure is safe and effective in treatment of portal hypertension with better clinical outcome,moderate homodynamic changes and good maintenance of hepatic functional reserve.