吻合器断流术对肝硬化门静脉血流动力学影响的临床评估

The clinical assessment of the influence of selective paraesophagogastric devascularization plus distal esophageal transection and reanastomosis with stapler on portal hemodynamics

目的:评价吻合器断流术对肝硬化患者门静脉系统血流动力学的影响。方法:2002年7月-2009年7月对38例肝硬化门静脉高压症食管静脉曲张破裂出血(esophageal variceal bleeding,EVB)患者分别行传统断流术(A组)及吻合器断流组(B组),其中A组12例,B组26例,分别于切脾前、后、断流术后测定自由门静脉压力(free portal venous pressures,FPP)。术后3～6个月上消化道造影或胃镜检查了解食管静脉曲张、门脉高压性胃病情况。术后6个月复查彩色多普勒超声检测门静脉直径(portal vein diameter,PVD)、门静脉流速(portal vein velocity,PVV)、门静脉血流量(portal venous flow,PVF),随访术后再出血情况。结果:A、B两组切脾后门静脉压力较切脾前下降,A组术后FPP为(2.32±0.19)kPa,较切脾后上升,B组术后FPP进一步下降为(1.80±0.15)kPa,较切脾后下降(P<0.05),B组术后FPP与A组比较差异有统计学意义(P<0.05);术后6个月复查彩超示:B组术后PVD、PVV、PVF均较A组显著减少(P<0.05);B组术后食管静脉曲张、门脉高压性胃病显著改善。术后无1例发生再出血。结论:吻合器断流术降低门静脉压力效果较持久,能显著改善食管静脉曲张,并降低术后再出血率,同时不会加剧门脉高压性胃病,是治疗门静脉高压症EVB的一种较理想的术式。

Objective： To evaluate the influence of paraesophagogastric devascularization plus distal esophageal transection and reanastomosis with stapler on portal hemodynamics.Methods： From July 2002 to July 2009,selective paraesophagogastric devascularization plus distal esophageal transection and reanastomosis with stapler（group A） and traditional paraesophagastric devascularization（group B） were performed in 38 patients of liver cirrhosis with portal hypertension and esophageal variceal bleeding（EVB）.There were 12 patients in Group A,and 26 patients in Group B.Among these patients,free portal venous pressures（FPP） were measured before cutting spleen,after cutting spleen and after paraesophagogastric devascularization respectively.After 3 to 6 months,in all cases the situation of esophageal varices and portal hypertensive gastropathy（PHG） were observed through upper gastrointestinal scanning or gastroscopy.After 6 months,in all cases portal vein diameter（PVD）,portal vein velocity（PVV）,and portal venous flow（PVF） were reexamined with colour Doppler ultrasound.Their postoperative rebleeding was followed up.Results： FPP was decreased in both groups after cutting spleen.FPP was increased after paraesophagogastric devascularization in group A（2.32±0.19）kPa,compared with after splenectomy.FPP was reduced to（1.80±0.15）kPa in group B after paraesophagogastric devascularization plus distal esophageal transection and reanastomosis,compared with after splenectomy,and the differences were significantly（P0.05）.After the operation FPP in group A was significantly higher than that in group B（P0.05）.Six months after the operation,PVD,PVV and PVF in group B decreased significantly,compared with those in group A（P0.05）.The condition of esophageal varices and PHG was significantly improved in group B.No rebleeding was found in all patients.Conclusion： Paraesophagogastric devascularization plus distal esophageal transection and reanastomosis with stapler could decrease portal venous pressure after operation for longer time,improve significantly the condition of the esophageal varices,decrease the rate of postoperative bleeding,and would not aggravate PHG.So it was a more ideal operation for treatment of EVB after portal hypertension.