肝硬化Child-PughC级门静脉高压症患者行脾切除贲门周围血管离断术的可行性

Feasibility of splenectomy and pericardial devascularization in patients with Child-Pugh grade C cirrhosis and portal hypertension

目的探讨肝硬化Child-PughC级的门脉高压症合并严重脾亢患者（血小板≤70×109／L），或首次出现食管胃底静脉曲张（GEV）出血患者行脾切除贲门周围血管离断术的可行性。方法回顾性分析复旦大学附属华山医院普外科2010年1月至2017年1月收治的具有GEV高危出血风险的肝硬化Child—PughC级门静脉高压行脾切除贲门周围血管离断术患者的临床资料，初步探讨手术的安全性、有效性以及术后并发症和病死率。结果32例患者符合研究标准。术前行保肝治疗，尽可能改善患者的肝功能。患者均行脾切除贲门周围血管离断术。患者术中出血量（208．0±102．0）ml、手术时间（2．2±0．3）h、住院时间（11．8±2．8）d。术后并发症有发热、伤口感染、腹水等，其中1例发生低血量休克合并急性肾衰竭死亡。术后长期随访患者门静脉血栓（PVT）发生率为12．5％（4／32），术后1年、3年、5年GEV再出血率分别为6．3％（2／32）、6．3％（2／32）、9．4％（3／32），患者5年总病死率为12．5％（4／32）。结论具有高危出血风险的肝硬化Child—PughC级门静脉高压症患者，在无明显手术禁忌，无条件行肝移植的情况下，通过充分的术前评估及积极的围手术期处理，及时行脾切除贲门周围血管离断术仍是可行的临床治疗选择。

Objective To evaluate the feasibility of splenectomy and pericardia1 devascularization in patients with Child-Pugh grade C cirrhosis, portal hypertension, and severe hypersplenism or after the first gastroesophageal variceal hemorrhage （GEV bleeding）. Methods From January 2010 to January 2017, the clinical data from patients with Child-Pugh grade C cirrhosis, portal hypertension with a high risk of GEV bleeding were retrospectively analyzed. These patients underwent splenectomy and pericardial devascularization at the Huashan Hospital Affiliated to the Fudan University. The safety and effectiveness of surgery, postoperative complications and mortality were further explored. Results Liver protection treatment was given before surgery to improve the liver function. Of the 32 patients who underwent splenectomy and pericardial devascularization, the operation time was （2.2±0.3） hours. The blood loss was （208.0± 102.0） ml and the hospital stay after surgery was （11.8±2.8） d. Postoperative complications included fever, wound infection and ascites. One patient died of hypovolemic shock and acute renal failure. The incidence of postoperative PVT was 12.5% （4/32）. The rates of GEV rebleeding at 1 year, 3 years, and 5 years after surgery were 6.3% （2/32）, 6.3% （2/32）, and 9.4% （3/32）. The 5-year overall mortality rate was 12.5% （4/32）. Conclusions In the absence of obvious surgical contraindications and with a lack of donor livers for liver transplantation, aggressive perioperative management, splenectomy and pericardial devascularization are a feasible option for patients with Child-Pugh grade C cirrhosis, portal hypertensionwith a high risk of GEV bleeding.