肝硬化门静脉高压症外科治疗程序

Surgical therapy procedure in cirrhosis with portal hypertension

肝硬化门静脉高压症的传统外科治疗主要是针对其最严重的并发症——食管胃底静脉曲张破裂出血。目前达成的共识是急性大出血以非手术治疗为主,如药物、内镜和三腔二囊管等;出血无法控制如果肝功能Child-Pugh分级A/B级者则可急诊手术,只要病人存在门静脉向肝血流,术式以断流术为主,如果Child-Pugh分级C级者可行经颈内静脉肝内门体分流术(TIPS)治疗。病人首次出血控制后预防再出血大多需要外科治疗。术前需明确病因,评估肝脏储备功能、门静脉高压症程度、肝脏和门静脉系统血流动力学状况等。传统外科手术方式主要为断流术、分流术和联合手术等。我们强调术式选择须依据门静脉系统血流动力学状况,各种术式均有明确的血流动力学状况的适应证。门静脉高压症出血病人中只有肝功能Child-Pugh分级C级经内科治疗无法改善者(终末期肝病)适合行肝移植。

Bleeding from esophagogastric varices is the most life-threatening complication of portal hypertension, which is the main target of traditional surgical therapy. It has been reached a consensus that non-operative therapy is primary during the period of acute variceal bleeding, such as pharmacotherapy, endoscopic therapy, triplelumen tube balloon tamponade and so on. In the case of refractory bleeding, emergency operation is suitable in patients provided that the liver dysfunction is not too severe （ Child- Pugh class A or B ）. Devascularization is the most suitable choice in emergency operation so long as there is hepatopetal blood flow in the portal vein. Transjugular intrahepatic portosystem shunt （TIPS） is suitable for the patients of Child-Pugh class C who are in emergency state. Most patients who survive a first variceal hemorrhage episode should receive surgical treatment to prevent recurrent episodes. The etiological factor（s） should be defined before operation, and it also should be evaluated that the hepatic functional reserve, degree of portal hypertension and hemodynamics of the liver and portal system. Mainly for the traditional surgical method includes devascularization, shunt surgery and shunt combined with devascularization surgery. We emphasize that selection of operative method must be based on portal vein hemodynamics, and the operative modality must have a definite hemodynamic status. Among those who bleed in portal hypertension, patients with only liver function Child-Pugh class C who can not be improved by medical treatment （end-stage liver disease） are suitable for liver transplantation.