脾切除联合贲门周围血管离断术后自由门静脉压力变化规律及其影响因素分析

Changing rules of free portal pressure and influencing factors after splenectomy combined with pericardial devascularization

目的总结脾切除联合贲门周围血管离断术后自由门静脉压力(FPP)的动态变化规律,分析其相关影响因素。方法采用回顾性横断面研究方法。收集2016年1月至2018年9月宁夏回族自治区人民医院收治的55例门静脉高压症患者的临床病理资料;男39例,女16例;中位年龄为46岁,年龄范围为17~67岁。联合术前CT门静脉造影检查和术中经胃网膜右静脉置管测压方法监测FPP。观察指标:(1)术中与术后FPP的比较。(2)术后第7天FPP动态变化。(3)Valsalva动作前后FPP的比较。(4)FPP与平均动脉压和心率的关系。正态分布的计量资料以Mean±SD表示,重复测量资料采用重复测量方差分析;配对资料采用配对t检验。采用直线相关分析相关性。结果(1)术中与术后FPP的比较:55例患者均行开腹脾切除联合贲门周围血管离断术,术中脾切除前、术中脾切除+贲门周围血管离断后、术后第1天和术后第7天FPP分别为(34±6)、(28±6)、(34±5)、(30±5)cmH2O(1 cmH2O=0.098 kPa),4者比较,差异有统计学意义(F=43.23,P<0.05)。术中脾切除前分别与术中脾切除+贲门周围血管离断后、术后第1天和术后第7天FPP比较,差异均有统计学意义(P<0.05);术中脾切除+贲门周围血管离断后分别与术后第1天和术后第7天FPP比较,差异均有统计学意义(P<0.05);术后第1天和术后第7天FPP比较,差异有统计学意义(P<0.05)。(2)术后第7天FPP动态变化:55例患者术后第7天00∶00~24∶00时段FPP分别为(30±5)、(29±5)、(29±5)、(29±5)、(28±5)、(28±5)、(28±5)、(29±5)、(29±5)、(30±5)、(30±5)、(30±5)、(31±5)、(31±5)、(31±5)、(31±5)、(31±5)、(32±5)、(31±5)、(31±5)、(31±5)、(31±5)、(30±5)、(30±5)cmH2O。FPP较高时段为12∶00~21∶00,FPP较低时段为01∶00~08∶00;FPP水平峰值时间为17∶00,FPP水平谷值时段为04∶00~06∶00。(3)Valsalva动作前后FPP的比较:55例患者Valsalva动作前后FPP分别为(30±5)cmH2O和(32±5)cmH2O,两者比较,差异有统计学意义(t=82.72,P<0.05)。(4)FPP与平均动脉压和心率的关系。直线相关分析结果显示:FPP与平均动脉压和心率均存在正相关,但相关性均不密切(r=0.10,0.16,P<0.05)。结论术中脾切除联合贲门周围血管离断后FPP显著下降,但术后又短期回升;FPP存在昼夜规律性波动,Valsalva动作可使FPP升高;FPP与平均动脉压和心率均存在正相关,但相关性均不密切。

Objective To summarize the changing rules of free portal pressure(FPP)after splenectomy combined with pericardial devascularization and investigate its influencing factors.MethodsThe retrospective cross-sectional study was conducted.The clinicopathological data of 55 patients with portal hypertension who were admitted to the People′s Hospital of Ningxia Hui Autonomous Region from January 2016 to September 2018 were collected.There were 39 males and 16 females,aged from 17 to 67 years,with a median age of 46 years.FPP was measured using CT portal vein angiography before splenectomy and intraoperative manometry after cantheterization to the right gastroepiploic veins.Observation indicators:(1)comparison between intraoperative and postoperative FPP;(2)dynamic changes of FPP at the seventh postoperative day;(3)comparison of FPP before and after Valsalva manoeuvre;(4)relationship of FPP with mean arterial pressure and heart rate.Measurement data with normal distribution were represented as Mean±SD.Repeated measurement data were analyzed using repeated ANOVA.Paired data were analyzed by the paired t test.The linear correlation analysis was done for relevance.Results(1)Comparison between intraoperative and postoperative FPP:55 patients underwent open splenectomy combined with pericardial devascularization.The FPP before splenectomy,after splenectomy combined with pericardial devascularization intraoperatively,at the first and the seventh day postoperatively was(34±6)cmH2O(1 cmH2O=0.098 kPa),(28±6)cmH2O,(34±5)cmH2O and(30±5)cmH2O,respectively,showing a statistically significant difference(F=43.23,P<0.05).The FPP before splenectomy was statistically significant different from the FPP after splenectomy combined with pericardial devascularization intraoperatively,at the first and the seventh day postoperatively,respectively(P<0.05).The FPP after splenectomy combined with pericardial devascularization intraoperatively was statistically significant different from the FPP at the first and the seventh day postoperatively,respectively(P<0.05).There was a statistically significant difference between FPP at the first and the seventh day postoperatively(P<0.05).(2)Dynamic changes of FPP at the seventh postoperative day:the FPP was(30±5)cmH2O,(29±5)cmH2O,(29±5)cmH2O,(29±5)cmH2O,(28±5)cmH2O,(28±5)cmH2O,(28±5)cmH2O,(29±5)cmH2O,(29±5)cmH2O,(30±5)cmH2O,(30±5)cmH2O,(30±5)cmH2O,(31±5)cmH2O,(31±5)cmH2O,(31±5)cmH2O,(31±5)cmH2O,(31±5)cmH2O,(32±5)cmH2O,(31±5)cmH2O,(31±5)cmH2O,(31±5)cmH2O,(31±5)cmH2O,(30±5)cmH2O,(30±5)cmH2O from 00∶00 to 24∶00 at the seventh day postoperatively.Level of FPP was higher from 12∶00 to 21∶00 and lower from 01∶00 to 08∶00,with a peak value at 17∶00 and valley value from 04∶00 to 06∶00.(3)Comparison of FPP before and after Valsalva maneuvre:the FPP was(30±5)cmH2O and(32±5)cmH2O before and after Valsalva manoeuvre,respectively,showing a statistically significant difference(t=82.72,P<0.05).(4)Relationship of FPP with mean arterial pressure and heart rate.Linear correlation analysis showed positive correlations of FPP with mean arterial pressure and heart rate respectively,but the correlation was not significant(r=0.10,0.16,P<0.05).ConclusionsFPP can be reduced significantly after splenectomy combined with pericardial devascularization intraoperatively and it rises briefly again after operation.FPP has regularly circadian fluctuations and is significantly increased by Valsalva Manoeuvre.There is a positive correlation of FPP with mean arterial pressure and heart rate respectively,but the correlation is not significant.