腹腔镜与开腹脾切除加门奇静脉断流术治疗门静脉高压症复发性上消化道出血疗效比较

Laparoscopic versus open splenectomy plus portaazygous devascularization in the treatment of patients with portal hypertension with recurrent upper gastrointestinal bleeding

目的比较腹腔镜与开腹脾切除加门奇静脉断流治疗门静脉高压症复发性上消化道出血的效果。方法回顾性分析西安交通大学医学部附属咸阳市中心医院肝胆外科2014年3月至2017年2月采用腹腔镜与开腹手术行脾切除加门奇静脉断流术患者的临床资料。根据手术人路分为腹腔镜组（A组，60例）和开腹组（B组，52例）。结果两组患者均无围手术期死亡。腹腔镜组患者术中出血量、手术时间、术后肛门排气时间、术后住院时间均低于开腹组[分别为（152．5±50．0）ml比（505．5±250．0）ml，（2．8±0．5）h比（3．9±0．5）h，（2．1±0．9）d比（3．6±1．2）d，（5．8±1．4）d比（8．6±2．4）d]，差异有统计学意义（均P〈0．05）。腹腔镜组术后近期并发症发生率低于开腹手术组（10．0％比36．5％）；术后1个月门脉系统血栓发生率高于开腹手术组（23．3％比11．5％）；肝功能优于开腹手术组，差异有统计学意义（P〈0．05）；术后1个月两组门静脉血流量和食管胃底静脉曲张分级比较，差异无统计学意义（P〉0．05）；术后1年再出血率和肝性脑病发生率低于开腹手术组，差异有统计学意义（P〈0．05）。两组术后1、3年生存率差异无统计学意义（P〉0．05）。结论腹腔镜下脾切除加门奇静脉断流具有创伤小、近远期疗效好等优点，可供临床选用。

Objective To compare the efficacies of laparoscopic versus open splenectomy plus portaazygous devaseularization in the treatment of patients with portal hypertension with recurrent upper gastrointestinal bleeding. Methods The clinical data of patients who underwent laparoscopic （ n = 60） versus open （ n = 52） splenectomy plus open portaazygous devaseularization in the Department of Hepatobiliary Surgery, the Center Hospital of Xianyang City, Xi＇an Jiaotong University Health Science Center from March 2014 to February 2017 were retrospectively analyzed. Results There was no perioperative death in the 2 groups. The amounts of intraoperative bleeding, the durations of the operation, the time of first flatus passed after operation and the duration of postoperative hospitalization were compared, and the differences were significantly different （t = 3. 288,2. 533,3. 325,2.823, P 〈 0.05 ）. There was no significant difference in the total hospitalization expenses （ t = 0. 651, P 〉 0. 05 ）. The incidence of postoperative complications was significantly higher in the open surgery group （ χ^2 = 7. 622, P 〈 0.05 ）. At 1-month after surgery, color doppler flow imaging （CDFI） showed no significant difference on the portal blood flow between the two groups （t = 0. 625, P 〉 0.05 ）. On gastroscopy, the esophageal and gastric varices were significantly improved, and there was no significant difference between the two groups （χ^ 2= 0. 718, P 〉 0.05 ）. Liver function was better in the laparoseopie group than the open group （ χ^2= 3. 765, P 〈 0.05 ）. Comparison of the rebleeding rates and the incidences of hepatic encephalopathy for the two groups at 1 year after operation showed significantly better outcomes for the laparoscopic group （χ^2 = 2.351, 1. 245, P 〈 0.05 ）. The 1-year and 3-year survival rates after operation （χ^2 = 0. 218, 0. 361, P 〉 0.05 ） were not significantly different. Conclusion Compared with laparotomy, laparoscopic splenectomy plus portaazygous devascularization had the advantages of less trauma, better short-term and long-term efficacies.