腹腔镜脾切除联合贲门周围血管离断术治疗肝硬化门静脉高压症效果分析

Effect of laparoscopic splenectomy combined with pericardial devascularization on cirrhotic portal hypertension

目的分析腹腔镜脾切除联合贲门周围血管离断术治疗肝硬化门静脉高压症的效果。方法选择2013年12月至2016年3月于河北医科大学第二医院治疗的肝硬化门静脉高压症患者56例。所有患者择期行完全腹腔镜脾切除联合贲门周围血管离断术。记录患者手术相关情况。结果 56例患者均顺利完成腹腔镜脾切除联合贲门周围血管离断术,其中用腹腔镜下切割缝合器(Endo-GIA)将脾蒂钳合后离断或七号线双重结扎后生物夹夹闭离断9例,因脾脏巨大暴露困难改行手助腹腔镜完成2例,其余45例均正常执行。手术时间为150～330 min、平均(221±36)min,术中出血量80～1 400 ml,平均(347±202)ml。所有患者均于术后1～3 d排气,术后引流液量为100～400 ml,平均(204±52)ml,并多于术后3～5 d拔管。其中12例因低蛋白原因出现腹腔积液,无术后出血二次手术病例,无一例出现切口感染、胰漏、胃漏、膈下积液和结肠损伤。24例患者因依从性差,随访丢失。余32例随访成功,脾功能亢进症状完全缓解且血常规三系提示正常。患者术后第1、3、7天血小板计数分别为(45±17)×10~9/L、(157±42)×10~9/L,(299±39)×10~9/L,脾功能亢进逐渐缓解。患者术后住院7～15 d,平均(9.0±1.0)d。其中4例出现门静脉血栓,未再发生呕血或黑便,无死亡病例。结论腹腔镜脾切除联合贲门周围血管离断术是肝硬化门静脉高压症的一种安全有效的治疗方案。

Objective To analyze the effect of laparoscopic splenectomy combined with pericardial devascularization on cirrhotic portal hypertension. Methods Fifty-six patients with cirrhotic portal hypertension from December 2013 to March 2016 in the Second Hospital of Hebei Medical University were enrolled. Operation data of laparoscopic splenectomy combined with pericardial devascularization were analyzed. Results All patients successfully completed operation; 9 cases had transection of splenic pedicle by laparoscopic cut stapler （Endo-GIA） or ligation and clipping; 2 cases of splenomegaly had hand-assisted laparoscopic surgery; 45 cases had routine surgical procedures. The average operation time was （221±36）min （150-330 min）; the average bleeding loss was （347±202）ml （80-1 400 ml）. All patients exhausted in 1-3 d and they were extubated in 3-5 d after operation; the average drainage volume was （204±52）ml （100-400 ml）. Twelve patients had ascites caused by low protein. No postoperative hemorrhage, incision infection, pancreatic leakage, gastric leakage, diaphragmatic pleural effusion and colonic injury occurred. Twenty-four patients lost follow-up. In 32 patients with complete follow-up data, postoperative 1, 3, 7 d platelet count were （45±17）×109/L, （157±42）×109/L, （299±39）×109/L respectively; hypersplenism gradually alleviated; the average postoperative hospital stay time was （9.0±1.0）d （7-15 d）. Four patients had portal venous thrombosis. No hematemesis, melena and death occurred after operation. Conclusion Laparoscopic splenectomy combined with pericardial devascularization is safe and effective in treatment of cirrhotic portal hypertension.