脾切除联合贲门周围血管离断术治疗特发性非硬化性门脉高压所致食管胃底静脉曲张破裂出血的疗效分析

Curative effect analysis of splenectomy and esophagogastric devascularization on esophageal and gastric varices bleeding in patients with idiopathic noncirrhotic portal hypertension

目的分析脾切除联合贲门周围血管离断术治疗特发性非硬化性门脉高压(INCPH)所致食管胃底静脉曲张破裂出血的效果及预后。方法采用回顾性研究方法,选取2016年1月至2017年12月首都医科大学附属北京友谊医院肝病中心、解放军总医院第五医学中心和首都医科大学附属北京地坛医院收治的INCPH所致食管胃底静脉曲张破裂出血的INCPH患者75例,根据是否受接受脾切除联合贲门周围血管离断术将患者分为手术组(32例)及非手术组(43例)。比较两组患者的病史、体征、肝功能评价指标包括终末期肝病模型(MELD)评分、Child-Pugh评分、ChildPugh分级。比较手术组与非手术组、手术组术前及术后2周的实验室检查指标,包括白细胞(WBC)、血红蛋白(HGB)、血小板(PLT)、丙氨酸氨基转移酶(ALT)、天门冬氨酸氨基转移酶(AST)、总胆红素(TBIL)、直接胆红素(IBIL)、白蛋白(ALB)、凝血酶原时间(PT)及凝血酶原活动度(PTA)等。随访24个月,比较两组患者的并发症情况,包括再出血率、肝性脑病发生率、门静脉血栓发生率、死亡率等。多因素Logistic回归分析引起患者死亡的相关危险因素。结果手术组与非手术组患者的病史、体征、肝功能指标均无统计学差异(P>0.05)。两组患者的WBC、HGB、PLT、ALT、AST、ALB,TBIL、IBIL、PT及PTA比较,差异均无统计学意义(P>0.05)。手术组患者的术后2周HGB及PLT均恢复至正常值,差异具有统计学意义(P<0.01),而WBC、ALT、AST、ALB、TBIL、IBIL、PT及PTA与术前比较,差异均无统计学意义(P>0.05)。随访期间,手术组(3例,9.4%)患者再出血率低于非手术组(14例,32.6%),差异具有统计学意义(P<0.01)。手术组与非手术组门静脉血栓发生率、肝性脑病发生率及死亡率比较,差异均无统计学意义(P>0.05)。多因素Logistic回归分析显示,患者死亡的独立危险因素为再出血(P=0.004)和门静脉血栓(P=0.047)。结论脾切除联合贲门周围血管离断术治疗INCPH引起的食管胃底静脉曲张破裂出血安全有效,疗效满意。

Objective To analyze the effect and prognosis of splenectomy and esophagogastric devascularization(SED)in the treatment of esophageal and gastric varices bleeding caused by idiopathic non sclerotic portal hypertension(INCPH).Methods Retrospective analysis of 75 patients with INCPH who were treated in three hospitals(complete data)in Beijing from January 2016 to December 2017 due to gastrointestinal bleeding caused by INCPH.The patients were divided into surgery group and non-surgery group according to whether they received splenectomy and esophagogastric devascularization,with 32 patients in surgery group and 43 patients in non-surgery group.The medical history,physical signs and liver function evaluation indexes including Model for end-stage liver disease(MELD)score,Child-Pugh score and Child-Pugh grade in surgery group and non-surgery group were compared.The laboratory examinations including white blood cell(WBC),hemoglobin(HGB)、platelet(PLT)、alanine transaminase(ALT)、aspartate aminotransferase(AST)、Albumin(ALB),Total bilirubin(TBIL)、Indirect bilirubin(IBIL)、prothrombin time(PT)and Prothrombin activity(PTA)of the two groups were compared and those data of the surgery group before and 2 weeks after surgery was also compared.Followed up for 24 months,the complications of the two groups were compared,including rebleeding rate,incidence of hepatic encephalopathy,incidence of portal vein thrombosis and mortality.Risk factors for death were analyzed by multi-factor logistic regression analysis.Results There was no statistical difference in the medical history,physical signs and liver function indexes between surgery group and non-surgery group.No significant difference was found in WBC,HGB,PLT,ALT,AST,ALB,TBIL,IBIL,PT and PTA between surgery and non-surgery groups(P>0.05).2 weeks after surgery,the HGB and PLT of the patients in surgery group recovered to the normal level,and the difference was statistically significant(P<0.01),while WBC,ALT,AST,ALB,TBIL,IBIL,PT and PTA had no statistical significance compared with before surgery(P>0.05).During the follow-up period,the rebleeding rate in surgery group(3 cases,9.4%)was lower than that in non-surgery group(14 cases,32.6%),the difference was statistically significant(P<0.01).There was no significant difference in the incidence of portal vein thrombosis,the incidence of hepatic encephalopathy and mortality between surgery group and non-surgery group(P>0.05).Multi-factor logistic regression analysis showed that the independent risk factors of death were rebleeding(P=0.004)and portal vein thrombosis(P=0.047).Conclusion Splenectomy and pericardial devascularization are safe and effective in the treatment of esophageal and gastric varices bleeding caused by INCPH.