原位脾切除联合贲门周围血管离断术的改进

Modified Spelenectomy and Pericardial Devascularization for Portal Hypertension

目的:探讨脾切除联合贲门周围血管离断术的改进方法。方法:采取改进的原位脾切除术,在保持脾脏原位状态下紧贴脾脏离断脾蒂及脾周韧带,最后离断脾上极的胃短血管。在贲门周围血管离断时采取紧贴胃及食管分离的选择性血管离断术,保留迷走神经前后干。经脾静脉插管并于术后向脾静脉内持续滴注肝素盐水以预防门静脉系血栓形成。结果:用该法治疗31例,术后门静脉自由压力(FPP)平均下降8cm水柱,手术出血量平均420mL,无手术死亡,术后近期无胃排空障碍及门静脉血栓形成。随访12～36个月,无复发出血及肝性脑病,术后6个月彩超发现门静脉矢状部血栓3例(9.68%)。结论:三贴近法脾切除加贲门周围血管离断术出血少,可有效降低门静脉压力;经脾静脉插管滴注肝素盐水可有效降低术后门静脉血栓发生率。

Objective：To evaluate the modification methods of splenectomy and pericardial devascularization.Methods：The modified anterior approach splenectomy includes dissection of the peri-spenic vessels and ligments before division of short gastric vessels.During pericardial devascularization,the dessection panel was close to the esophagus and the stomach.Both the anterior and posterior venus trunks were protected.Intraoperative splenic venous cannulation was done forpostoperative infusion of heparin on the purpose of prevention of portal venous thrombosis.Results：Thirty-one patients accepted this modified operation.The average reduction of free portal pressure（FPP）was 8 cm water column.The amount of operating bleeding was 420 mL on average.There was no operating death,no perioperative gastric paralysis and portal venous thrombosis 。By 12~36 months＇follow-up,there was no hepatic coma and recurrence of bleeding.Intrahepatic portal venous thromboses were detected with Doppler in 3 cases（9.68%）at the sixth postoperative month.The thromboses did not change during the follow-up and new case was not found.Conclusions：Splenectomy plus pericardial devascularization by the three close approaches gets less operating bleeding and effectively reduce the portal venous pressure.Infusion of heparin through the splenic venus cannulation is effective in prevention of portal venous thrombosis.