脾大部切除术治疗肝硬化门静脉高压症患者的远期疗效

Long-term efficacy of subtotal splenectomy due to portal hypertension in cirrhotic patients

目的 分析肝炎后肝硬化门静脉高压症患者术后随访指标,评价脾大部切除大网膜胸骨后固定术治疗门静脉高压症的远期疗效.方法 回顾性分析1999年至2014年采用脾大部切除大网膜胸骨后固定术治疗肝硬化门静脉高压症的65例患者手术后生存率、再出血率及辅助检查指标的变化.结果 患者4年内死亡4例,4年生存率为94％,11年生存率为60％.术后食管胃底静脉曲张再出血11例（17％）.术后6年和11年白细胞和血小板较术前明显升高（P＜0.05）;门静脉直径、门静脉血流量、脾动脉血流量较术前明显缩小或下降（P＜0.05）;脾脏长径、厚度、横截面积较术前明显缩小（P＜0.05）.血清巨噬细胞集落刺激因子（M-CSF）、粒细胞集落刺激因子（GM-CSF）水平较术前明显降低（P＜0.05）;CD3＋T细胞、CD4＋T细胞、CD8＋T细胞百分比较术前明显升高（P＜0.05）;IgA、IgM、IgG、Tuftsin水平与术前比较无变化（P＞0.05）.15例术后数字减影血管造影（DSA）显示门上腔静脉侧支循环形成.结论 脾大部切除大网膜胸骨后固定术可有效控制肝硬化门静脉高压症患者的出血,纠正脾亢,并保留脾免疫功能,部分患者长期生存.

Objective To analyze the important factors for follow-up in postoperative patients with portal hypertension （PHT） due to post-hepatitis cirrhosis,and to evaluate the long-term efficacy of subtotal splenectomy plus retrosternal fixation of greater omentum to treat PHT.Methods The post-operative survival rate,rebleeding rate and auxiliary examination indices of 65 patients,who were treated by subtotal splenectomy plus retrosternal fixation of the greater omentum for PHT between 1999 and 2014 were reviewed retrospectively.Results Four patients died within 4 years of surgery,with a 4-year survival rate of 94%,the 11-year survival rate was 60%.Eleven patients （17%） developed rebleeding from esophagogastric varices.The white blood cell and platelet counts were higher 6 and 11 years postoperatively when compared with the pre-operative values （P 〈 0.05）.Portal venous diameter,portal venous flow volume,.splenic artery flow volume,as well as splenic length,thickness,and average cross-sectional areas were significantly constricted or decreased （P 〈 0.05）.The proportions of serum CD3 ＋ T cells,CD4 ＋ T cells,and CD8 ＋ T cells increased （P 〈 0.05）,while the serum levels of macrophage colony-stimulating factor and granulocyte colonystimulating factor were significantly decreased （P 〈 0.05）.There was no significant change in the serum levels of IgA,IgM,IgG,and Tuftsin （P 〉0.05）.DSA demonstrated that in 15 patients collateral circulations formed between the portal vein and the superior vena cava.Conclusions Subtotal splenectomy plus retrosternal fixation of the greater omentum provided longterm results in prevent bleeding from esophagogastric variceal bleeding in patients with PHT.The operation corrected hypersplenism,and preserved splenic immune function.Longterm survival is expected in some patients with PHT.