脾切除对肝硬化肝脏的综合作用的临床研究

Study on the comprehensive effect of splenectomy on liver cirrhosis

目的探讨脾切断流术对肝硬化肝脏的作用及机制。方法前瞻性留取首都医科大学附属北京佑安医院2013年5月至2014年10月共54例肝硬化门静脉高压患者脾切除前后不同时间点的临床和实验室检查资料,比较手术前后的肝脏血管内径和血流,血清一氧化氮(NO)、内皮素-1(ET-1)等血流调节因子,白细胞介素-6(IL-6)、肝细胞生长因子(HGF)、转化生长因子-β1(TGF-β1)、基质金属蛋白酶1(MMP1)等肝再生和肝纤维化相关因子的变化。结果54例患者中男性31例,女性23例,年龄(45.5±10.2)岁。自由门静脉压从脾切除前的(37.0±7.1)cmH_(2)O(1 cmH_(2)O=0.098 kPa)下降到术后的(26.1±5.7)cmH_(2)O,差异有统计学意义(P<0.05)。脾切除术后肝动脉内径(4.0±1.0)mm较术前(3.1±0.7)mm明显增加,门静脉内径(11.9±2.0)mm较术前(13.1±1.9)mm明显减小,差异有统计学意义(均P<0.05);同时肝动脉流速和血流量增加,门静脉流速和血流量减小。血清NO在脾切除术后即刻升高且持续处于高水平;血清ET-1在脾切除术后2 d下降且低水平波动。血清IL-6和HGF在脾切除术后2 d明显上升,在术后7 d和1个月缓慢下降。脾切除术后血清TGF-β1、MMP1明显升高,血清内毒素水平明显降低,差异有统计学意义(均P<0.05)。结论脾切除术诱导了肝硬化患者肝脏血流重塑、肝细胞再生以及肝纤维化的逆转。对肝硬化肝脏产生保护作用。

Objective To study the impact and the mechanism of splenectomy combined with pericardial devascularization on cirrhotic livers.Methods Serum samples and clinical data were collected preoperatively and postoperatively from 54 patients with cirrhosis who underwent splenectomy combined with pericardial devascularization from May 2013 to Oct 2014 at Beijing You’an Hospital,Capital Medical University.Changes in hepatic arterial and portal venous blood flow,liver function and fibroscan results were analyzed.The levels of nitric oxide(NO),endothelin-1(ET-1),interleukin-6(IL-6),hepatocyte growth factor(HGF),transforming growth factor-β1(TGF-β1)and matrix metalloproteinase 1(MMP1)were measured.Results There were 31 males and 23 females,aged(45.48±10.21)years.Free portal vein pressure decreased significantly from(37.0±7.1)cmH_(2)O(1 cmH_(2)O=0.098 kPa)to(26.1±5.7)cmH_(2)O after surgery(P<0.05).Significant increases in postoperative lumen diameter(4.0±1.0)mm vs(3.1±0.7)mm were observed,accompanied by increase in peak flow velocity and blood flow of the hepatic artery.Significant deductions in lumen diameter(11.9±2.0)mm vs(13.1±1.9)mm,accompanied by reduction of peak flow velocity and blood flow of the portal vein were observed following surgery(all P<0.05).The NO level was significantly elevated immediately after splenectomy and was subsequently remained at high levels.The ET-1 level decreased 2 days after surgery and became fluctuated at low levels.The IL-6 and HGF levels increased significantly 2 days after surgery and decreased gradually after 7 days and 1 month,respectively.The TGF-β1 and the MMP1 levels increased after surgery.The endotoxin level decreased significantly after surgery(all P<0.05).Conclusion Splenectomy combined with pericardial devascularization induced hepatic blood flow restoration,hepatocyte regeneration and reversal of fibrosis in cirrhotic livers.Splenectomy has a protective effect on cirrhotic liver when combined with pericardial devascularization.