脾大部切除及食管横断吻合术治疗肝硬化门静脉高压症的血流动力学研究

Portal veinous hemodynamics after subtotal splenectomy and portaazygous devascularization

目的评价脾大部切除、残脾腹膜后包埋及食管横断吻合术对肝硬化门静脉高压症患者门静脉血流动力学的影响。方法将40例门静脉高压症患者随机分为研究组和对照组，每组20例。均进行食管横断吻合术，对照组做全脾切除，研究组保留部分带血管蒂脾脏移植于腹膜后。手术前后用三维动态增强磁共振血管成像测量门静脉主干的管腔横截面面积、血流量、血流速度和流向；观察自体移植脾在腹膜后的血供及侧支循环。结果两组术前均存在胃底食管曲张静脉，术后6个月MRA复查均消失或改善。术后6个月两组门静脉主干的管腔横截面积明显减少[研究组（1．81±0．73）cm^2比（1．20±0．52）cm^2，P〈0．01；对照组（1．78±0．52）cm^2比（1．30±0．12）cm^2，P〈0．01]；术后两组门静脉主干的平均流速均下降[研究组（9．86±0．10）cm／s比（7．06±1．92）cm／s，P〈0．01；对照组（10．0±0．6）cm／s比（8．2±2．4）cm／s，P〈0．01]，且研究组少于对照组（P〈0．01）；术后两组门静脉主干的平均流量均下降[研究组（15．0±1．9）ml／s比（10．5±2．7）ml／s，P〈0．01；对照组（14．9±2．1）ml／s比（11．6±2．1）ml／s，P〈0．01]，且研究组少于对照组（P〈0．05）。移植脾在腹膜后成活，并建立了广泛的侧支循环。结论脾大部切除、带血管蒂残脾腹膜后移植及食管横断吻合术治疗肝硬化门静脉高压症不仅保留了脾脏的功能，而且具有断流和分流为一体的联合性术式的作用。

Objective To evaluate perioperative portal hemodynamic alterations in cirrhotic patients undergoing subtotal splenectomy, pedieled spleen remnant retroperitoneal transplantation plus lower esophagus transection in the treatment of portal hypertension. Method Forty patients with cirrhotic portal hypertension were randomly allocated into 2 groups ： splenic transplantation group （ n = 20 ）, in which patients underwent subtotal splenectomy with pedicled remnant spleen retroperitoneal transplantation and cardia-esophageal devaseularization and transection, and control group （n = 20 ） , in which splenectomy and eardia-esophageal devaseularization and transection were performed. The cross section area, blood velocity and flow and collateral circulation of portal parameters were comparatively evaluated by 3D DEC MRA, and the size of remnant spleen, blood flow and collateral circulation of retroperitoneal transplanted spleen were comparatively assessed. Results At 6-month after operation, the disappearance of esophageal-gastric varices in two groups was similar, and the cross section areas of main portal vein （MPV） in two groups all decreased postoperatively, in study group it was （ 1.81± 0. 73 ） cm2 vs. （ 1.20 ±0. 52 ） cm^2, P 〈 0.01 ; in control group it was （1.78 ±0. 52）era2 vs. （1.30 ±0. 12）cm^2, P〈0. 01. The mean blood velocity of MPV decreased postoperatively, in study group it was （9. 86 ± 0. 10 ） em/s vs. （ 7.06 ± 1.92 ） cm/s, P 〈 0. 01 ; In control group it was （ 10.0 ± 0. 6） cm/s vs. （8.2 ±2. 4） cm/s, P 〈 0. 01. The mean blood flow velocity of MPV in study group was lower postoperatively than that in control group（ P 〈 0. 01 ）. The mean blood flow volume of MPV decreased postoperatively from （ 15.0 ± 1.9 ） ml/s to （ 10. 5 ±2. 7 ） ml/s, P 〈 0.01 in study group ; and from （ 14. 9 ± 2. 1 ） ml/s to （ 11.6 ±2. 1 ） ml/s, P 〈 0.01 in control group. The mean blood flow volume of MPV in study group was lower postoperatively than that in control group （P 〈 0. 05 ） . A significant collateral formation was observed around the retroperitoneally translocated pedicled remnant spleen. Conclusions Compared with splenectomy, subtotal splenectomy, retroperitoneal translocation of the pedicled remnant speen helps to preserve splenic function as well as to increase retroperitoneal collateral formation which is conducive to further decreasing the portal veinous pressure.