门静脉高压症复发性上消化道出血的腹腔镜手术治疗

The treatment for recurrent upper digestive tract hemorrhage with portal hypertension by laparoscopic surgical technique

目的探讨应用腹腔镜脾切除术(LS)及门奇断流术治疗门静脉高压症复发性上消化道出血的手术技巧及临床应用的安全性。方法回顾性分析2010年5月至2015年4月对56例门静脉高压症复发性上消化道出血患者采用腹腔镜手术治疗的临床资料。结果 56例患者中,51例患者完成LS及门奇断流术,其中采用一级脾蒂离断法13例,采用二级脾蒂离断法38例;手术时间(2.8±0.5)h、术中出血量(156.8±33.5)ml、术后肛门排气时间(3.1±1.3)d、术后住院时间(6.1±1.3)d;术后胸腔积液2例,轻度腹腔积液1例;有2例发生轻度胰漏,经腹腔引流后痊愈。全组无围手术期死亡。因术中出血,2例改为手助腹腔镜手术,3例完全中转开腹手术;非完全腹腔镜手术中转率为8.9%。随访1年内再出血3例,再出血率5.4%。术后1、3、5年生存率分别为96.4%(54/56)、87.5%(28/32)、75.0%(15/20)。结论应用LS及门奇断流术治疗门静脉高压症复发性上消化道出血,具有创伤小、出血少、恢复快、并发症发生率低的优点。只要严格掌握适应证,术前精确评估,术中精细操作并做好中转应急处理,术后精心管理,该术式是安全可行的,其远期疗效也是肯定的。

Objective To investigate the operative skills and clinical safety of the treatment for recurrent upper digestive tract hemorrhage with portal hypertension by laparoscopic surgical technique. Methods The clinical data of 56 patients who suffered from recurrent upper digestive tract hemorrhage with portal hypertension by laparoscopic surgical technique from May. 2010 to Apr. 2015 were retrospectively analyzed. Results In 56 cases, Total laparoscopic splenectomy plus portoazygous devascularization wered in 51 cases, 13 cases of primary splenic pedicle from breaking method is adopted, the secondary spleen was 38 cases. The operative time was （2. 8 ± 0. 5 ） hours. The intraoperative bleeding was （156. 8 ± 33. 5） ml. The time taken for the bowel to return function was （3.1 ± 1. 3） days. The hospitalization time was（6. 1 ±1.3）days. Postoperative pleural effusion was in 2 cases, mild ascites in 1 case ; 2 cases of mild pancreatic leakage were cured by abdominal drainage. There was no perioperative mortality in the whole group. Due to bleeding, 2 cases changed to hand assisted laparoscopic surgery, three cases of complete conversion to open surgery. The conversion rate of non complete laparoscopic surgery was 8.9%. The total patients were followed up for 1 year, rebleeding wered in 3 cases, the rebleeding rate was 5. 4% , the 1,3,5 years survival rate were 96. 4% （54/56） , 87. 5% （28/32） ,75. 0% （ 15/20） . Conclusions Laparoscopic splenectomy and portoazygous devascularization for portal hypertension with recurrent upper digestive tract bleeding, with less trauma, less bleeding, faster recov-ery, the advantages of the low incidence of complications was advantageous. As long as strict indications, accurate preoperative assessment, intraoperative fine operation and make transit emergency treatment, after careful management, the procedure is safe and feasible. Its longterm effect is positive.