肝硬化门静脉高压症合并恶性梗阻性黄疸的外科治疗经验

Surgical experience in treating malignant obstructive jaundice background on cirrhotic portal hypertension

目的探讨肝硬化门静脉高压症合并恶,性梗阻性黄疸的临床特点与处理方案。方法对首都医科大学北京地坛医院肝胆外科2005-2008年收治的31例肝硬化门静脉高压症合并恶性梗阻性黄疸病人的临床资料进行总结。结果 31例均合并食管-胃底静脉曲张,26例中重度曲张病人术前行胃镜曲张血管治疗。18例行胆管引流,术后早期恢复良好,但均于随访期内死亡,死亡原因为胆管感染、胆管再阻塞、肿瘤进展、上消化道出血和肝功能衰竭。13例根治性切除病人无手术死亡病例,术后并发症未见明显升高,均恢复出院。随访期内2例胆囊癌根治术与2例根治性胰十二指肠切除术病人死于肿瘤转移。结论肝硬化门静脉高压症合并恶性梗阻性黄疸治疗困难,治疗方案需考虑肿瘤部位、手术解剖可切除性、肝脏储备功能、食管-胃底曲张静脉程度等。术前胃镜下曲张静脉治疗可预防术后上消化道出血,姑息性减黄治疗可近期改善生活质量,延长生命,远期疗效差。充分术前评估和术前准备可提高根治性切除安全性,远期预后与肿瘤性质有关。

Objective To summarize and approach the clinic features and surgical treating procedures of malignant obstructive jaundice background on cirrhotic portal hypertension.Methods To analyze the clinical data of 31 patients with malignant obstructive jaundice background on cirrhotic portal hypertension hospitalized in department of Surgery of the Beijing DiTan Hospital from 2005 to 2008.Results The varices were detected in all 31 cases.26 cases among the total cases were severe varices and were accepted with endoscope treatments in pre-operative time.18 cases had smooth recovery in early time of biliary tract drainages but them all dead in follow-up periods.The infection of biliary tract,biliary tract obstruction again,tumour progression,upper gastrointestinal hemorrhage and liver function failure were predominant dead reasons.There were no dead cases in 13 radical excision cases and the operative complications did not obviously rise.2 carcinoma of gallbladder cases and 2 periampullary carcinoma cases were died from tumor metastasis in follow-up periods.Conclusion It is a difficult problem to select a suitable medical method for malignant obstructive jaundice patients if they had cirrhotic portal hypertension background.Main factors should be pondered in pre-operative time such as tumor location,whether or not respectable tumor,liver reserve function,varices degree and so on.As a summary,it is necessary to use endoscope treating varices in pre-operative time in order to prevent post-operative varices bleeding.For radical excision operation cases,careful evaluation and sufficient preparation in pre-operative time could elevate operation security.Although biliary tract drainages could improve life quality and prolong living periods in short time,it is regretful that it had a worse long time therapeutic efficacy.