脾动脉瘤外科手术与腔内治疗的临床疗效比较

Comparison of clinical efficacy between surgical operation and endovascular treatment of splenic artery aneurysm

目的探讨脾动脉瘤(SAA)外科手术与腔内治疗的临床疗效。方法收集2012年1月至2021年12月中国医科大学附属盛京医院收治的43例SAA患者临床资料,根据手术方式的不同将其分为开腹组(n=17,行开腹手术)、腹腔镜组(n=10,行腹腔镜手术)、腔内组(n=16,行腔内治疗)。采用腹部增强计算机断层扫描(CT)或计算机断层扫描血管成像(CTA)评估SAA的位置、大小、形态以及动脉变异情况,观察3组患者的治疗情况,比较3组患者手术时间、住院时间、住院费用,统计3组患者术后并发症发生情况。结果开腹组患者行SAA及脾切除15例,术后血小板均出现升高趋势且术后第9天最高,其中,2例患者术后复查时发生门静脉血栓,但均无明显临床症状;脾动脉近、远端结扎+脾动脉瘤旷置2例,术后均未发生严重并发症。腹腔镜组患者行脾动脉近、远端结扎+脾动脉瘤旷置/切除10例,无中转开腹手术,无脾脏联合切除术,术中2例患者出现脾下极缺血表现(颜色变暗),术后血小板无明显变化、无严重并发症。腔内组患者采用弹簧圈进行脾动脉栓塞14例,同时行SAA瘤腔填塞术7例,1例限制性破裂性SAA腔内治疗效果不佳转为开腹手术,1例置入覆膜支架隔绝SAA,术后发生脾梗死3例,血小板无明显变化。3组患者手术时间、住院时间、住院费用比较,差异均有统计学意义(P<0.05)。腔内组患者的手术时间短于开腹组、腹腔镜组患者,腹腔镜组患者的手术时间短于开腹组患者,差异均有统计学意义(P<0.05)。腔内组、腹腔镜组患者的住院时间均短于开腹组患者,差异均有统计学意义(P<0.05)。开腹组、腹腔镜组患者的住院费用均低于腔内组患者,腹腔镜组患者的住院费用低于开腹组患者,差异均有统计学意义(P<0.05)。结论开腹手术、腹腔镜手术、腔内治疗均可作为SAA的治疗方案,应根据瘤体大小、部位、是否有破裂、患者经济情况等综合考量,个体化优化治疗。腹腔镜手术及腔内治疗是微创、相对安全、恢复较快的SAA治疗方案,开腹手术虽然创伤大,但仍然是重要的治疗方案,是破裂性SAA或微创治疗失败时的首选治疗手段。

Objective To explore the clinical efficacy of surgical operation and endovascular treatment of splenic artery aneurysm(SAA).Method A total of 43 SAA patients in Shengjing Hospital of China Medical University from January 2012 to December 2021,according to different surgical methods,they were divided into open surgery group(n=17,given open surgery),laparoscopy group(n=10,given laparoscopic surgery),and endovascular group(n=16,given endovascular therapy).The position,size,shape and arterial variation of SAA were evaluated by abdominal enhanced computer tomography(CT)or computer tomography angiography(CTA).The treatment of the three groups of patients was observed.The operation time,hospitalization time and hospitalization cost of the three groups of patients were compared.The postoperative complications of the three groups of patients were counted.Result A total of 15 cases underwent resection of SAA and splenectomy in open surgery group,and postoperative platelets increased in all patients,which achieved peak at 9 days after surgery,among them,2 cases developed portal vein thrombosis without significant clinical symptoms;2 cases underwent proximal and distal ligation of splenic artery with exclusion of SAA without severe complications.In laparoscopy group,10 cases underwent combination of proximal and distal splenic artery ligation of SAA with exclusion/resection of aneurysms,without conversion to laparotomy and concomitant splenectomy,2 cases experienced intraoperative severe ischemia under the spleen(darkish color),there were no significant change of postoperative platelet and severe complications.In endovascular group,14 cases underwent embolization of splenic artery with spring coil,7 cases underwent concurrent embolization of SAA,1 case with SAA contained rupture was converted to open surgery,1 case underwent stent graft implantation for aneurysm exclusion,3 cases developed spleen infraction without significant change of platelet.There were significant differences for operation time,hospitalization time and cost(P<0.05).The operation time of endovascular group was shorter than that of open surgery group and laparoscopic group,and the operation time of laparoscopic group shorter than that of open surgery group,the differences were statistically significant(P<0.05).The hospitalization time of endovascular group and laparoscopic group were shorter than that of open group,the differences were statistically significant(P<0.05).The hospitalization costs of open surgery group and laparoscopic group were lower than those of endovascular group,and the hospitalization costs of laparoscopic group was lower than that of the open surgery group,the differences were statistically significant(P<0.05).Conclusion Open surgery,laparoscopic surgery and endovascular therapy are feasible techniques for SAA treatment.The size and location of tumors,presence of rapture and economic condition should be taken into consideration comprehensively to develop individualized treatment.Laparoscopic surgery and endovascular therapy are safe,less invasive and fast recovery procedures.Open surgery is still an important and sometimes final solution for SAA when treating rapture SAA or facing failure of minimally invasive surgery,although it might be more invasive.