脾切断流术后门脉血栓形成22例

目的:研究现阶段门静脉血栓的真实发生率和目前术后抗凝治疗的效果,并探讨血栓形成的原因及治疗方法.方法:对2008-06/2010-10收集的58例患者进行回顾性研究,根据患者术后是否发生血栓分为血栓组和非血栓组,对血栓发生率、部位、危险因素及抗凝效果进行了分析.结果:58例患者中,共有22例患者在术后发生了血栓,其中1例患者形成肠系膜上静脉血栓,5例患者术后形成脾静脉血栓,13例患者在门静脉系统的多个部位同时形成了血栓(混合性血栓).血栓的总体发生率为37.93%.血栓组和非血栓组患者在脾脏质量和术后门脉流速上存在显著差别(1464g±521gvs1071g±349g;7.74cm/s±1.92cm/svs15.59cm/s±2.84cm/s;均P<0.05),血栓组血小板计数术虽然高于未发生血栓组,但差异不显著(P>0.05).结论:血小板计数和脾脏质量是术后患者发生门静脉血栓的重要因素.早期使用低分子肝素、华法林进行全身抗凝能有效地预防肝炎肝硬化门静脉高压症脾切除术后门静脉系统血栓的形成,并极大地改善了这类患者的预后.

肝硬化合并门脉血栓形成的危险因素分析

目的:探讨肝硬化合并门脉血栓形成(PVT)的危险因素。方法:选取88例肝硬化合并PVT患者(简称为PVT组)和肝硬化未合并PVT的患者88例为对照组,统计分析两组患者的一般资料、实验室相关检查指标,采用多因素分析法探讨肝硬化并发PVT的危险因素。结果:两组患者的年龄、性别、基础病因、合并高血压、合并糖尿病、WBC、PLT、TBil、INR、APTT、FIB、PT、MELD评分差异无统计学意义(P> 0. 05); PVT组患者的Hb、Alb、D-D、门静脉主干内径宽度、脾静脉内径宽度与对照组比较差异具有统计学意义(P <0. 05);采用非条件Logistic回归分析结果显示:Hb和Alb降低、D-D升高、门静脉主干内径宽度、脾静脉内径宽度增加是肝硬化患者并发PVT的独立危险因素(P <0. 05)。结论:Hb和Alb降低、D-D升高、脾静脉内径宽度增加是肝硬化患者并发PVT的独立危险因素。

聚桂醇联合组织胶治疗食管胃静脉曲张后门脉血栓形成的预测

目的分析内镜下聚桂醇联合组织胶治疗食管胃静脉曲张预防再出血后患者门脉系统血栓形成的危险因素,建立预测模型并验证该模型的准确率。方法收集2014年1月至2018年12月就诊于北京地坛医院的303例肝硬化并发食管胃静脉曲张破裂出血患者,对其行内镜下聚桂醇联合组织胶治预防再出血,随访观察1年,分析其中223例患者的临床资料,包括年龄、性别、病因、生化指标、Child-Pugh评分、静脉曲张程度、门脉血管宽度等指标。Logistic回归分析筛选出治疗后血栓形成的独立危险因素,并建立预测模型,应用80例患者的临床资料验证该预测模型的准确率。结果223例患者中1年内门脉血栓形成55例(24.66%),Logistic回归分析显示,左支门脉宽度(OR=1.414,95%CI:1.209~1.654,P=0.000)、右支门脉宽度(OR=1.267,95%CI:1.108~1.447,P=0.000)、食管静脉曲张程度(OR=2.033,95%CI:1.284~3.217,P=0.000)是治疗后血栓形成的独立危险因素,联合3个危险因素建立预测模型,得到ROC曲线下面积为0.862,cut-off值为-2.005。80例患者行交叉验证,该预测模型的准确率为95.0%。结论重度食管静脉曲张、左支门脉及右支门脉的宽度增加是治疗后形成血栓的高危因素,三者拟合模型预测血栓形成率准确率可达95.0%,具有一定的预测价值。

超声诊断青少年因肝硬化致门脉系统血栓一例

门静脉系统血栓形成是指发生在门静脉主干、肠系膜上静脉、肠系膜下静脉或脾静脉的血栓，是一种临床较为少见的深部血管阻塞性疾病。本病主要见于中老年患者，多累及门静脉、肠系膜下静脉及脾静脉，累及肠系膜下静脉者较罕见。由于发病时缺乏特异的临床症状和体征，且其病隋复杂，很难在发病早期确诊，处理不及时可出现肠管坏死、感染性休克甚至死亡。本文就笔者在临床工作中遇到的1例罕见病例做一报道。

肝硬化脾切除术后并发门脉内巨大血栓一例临床病理报告

女患55岁,因结节性肝硬化脾切除大网膜包肾术后24年,呕血100ml急诊入院。病人于1962年在首都医院行脾切除大网膜包肾术,术后24年一般情况好。本次入院前5个月曾呕血一次约1000ml,经双囊三腔管压迫止血。入院后9天内共发生3次大呕血,经双囊三腔管压迫、大剂量垂体后叶素及20％孟氏液局部治疗效果不佳,出血后第10天出现原发性腹膜炎,麻痹性肠梗阻,肝性脑病等症状,经用大剂量氨苄青霉素、氧哌嗪青霉素、妥布霉素、谷氨酸、精氨酸、支链氨基酸、左旋多巴等治疗病情无好转,6天后终因抢救无效死亡。尸检所见:结节性肝硬化,食道上中下段自上而下纵行排列4个静脉破裂点。胃肠内血性内容1500ml。

腹腔镜脾切除治疗肝硬化门脉高压性脾亢患者术后门脉血栓的危险因素

目的：探讨腹腔镜脾切除治疗门脉高压性脾功能亢进患者术后并发门脉血栓（ PVST）的危险因素。方法回顾性分析2013年1月至2014年4月扬州大学临床医学院收治的62例施行腹腔镜脾切除治疗门脉高压性脾功能亢进患者的临床资料。根据术后第七天有无PVST，将患者分为非PVST组（ n＝36）和PVST组（ n＝26），分析两组患者的15种围手术期变量。结果单因素分析显示，PVST组患者的年龄和门脉主干内径均高于非PVST组，而门脉主干血流速度则低于非PVST组，差异均有统计学意义（均P＜0．05）。将此三个变量由小到大分组后，与术后PVST进行相关性分析，相关性最大的值分别为年龄＞50岁、门脉主干内径＞13 mm和门脉主干血流速度＞18 cm／s。以它们为自变量，以术后PVST 为因变量进行 logistic 回归分析，结果显示年龄＞50岁和门脉主干内径＞13 mm是术后发生PVST的独立危险因素，而门脉主干血流速度＞18 cm／s则为独立保护因素。结论年龄＞50岁和门脉主干内径＞13 mm是腹腔镜脾切除术后发生PVST的独立危险因素，而门脉主干血流速度＞18 cm／s是独立保护因素。

肝硬化门脉高压症并发血栓形成机制和治疗研究进展

肝硬化门脉高压症并发血栓是临床研究实践过程中面临的难题。本文通过对其形成机制和治疗相关研究进展进行总结,重点介绍了近年来国内外关于肝硬化门脉高压并发门脉血栓发生机制和治疗进展。目前认识的主要发生机制包括肝星状细胞的活性、内皮细胞的功能、机体促凝血和凝血抑制失衡等,治疗措施包括低分子肝素等抗凝治疗、β受体阻滞剂和其他药物,如辛伐他汀、利福昔明和益生菌等联合应用以降低门脉压力治疗、提高一氧化氮合成酶磷酸化水平和针对线粒体的抗氧化治疗等措施。

抗磷脂综合征合并食管胃底静脉曲张破裂出血1例

为提高对抗磷脂综合征相关性上消化道出血的诊疗认识,对首都医科大学附属北京朝阳医院合作单位-河北燕达医院收治的1例抗磷脂综合征合并门静脉血栓、食管胃底静脉曲张破裂出血的患者进行报道,并对此患者抗凝时机及内镜下治疗的选择进行探讨,拟为临床诊治此类疾病提供更多的经验参考。

土三七致肝窦阻塞综合征8例临床特点分析及文献复习

目的分析土三七导致肝窦阻塞综合征(Hepatic sinusoidal obstruction syndrome,HSOS)临床特点及治疗预后。方法回顾性分析8例服用土三七致HSOS患者的临床资料,分析临床特点、治疗方案及预后。结果本文回顾分析了2010—2019年首都医科大学附属北京地坛医院诊断为HSOS的17例患者,明确有土三七用药史8例。8例患者平均年龄(59.38±9.46)岁,主要为男性,8例患者均为农民,主要临床表现为纳差、腹胀、水肿、黄染、腹痛。腹部CT扫描,可见肝脏显示地图状增强;腹部核磁可见肝内斑片状稍长T1、T2异常信号。其中出现门脉血栓形成4例,1例患者出现下肢静脉血栓。8例患者除常规治疗外,2例患者抗凝治疗。5例患者好转出院,定期门诊随访,3例患者死亡。结论土三七致HSOS高危人群为老年男性,农民为主,可引起严重的肝功能损伤和凝血功能异常,合并门脉血栓比例较高,应更加注重抗凝治疗,加强健康用药宣传。

脾切除术后门脉系统血栓形成的高危因素多元Logistic回归模型分析

目的应用多元Logistic回归模型分析脾切除术后门脉系统血栓形成的高危因素,为临床治疗提供理论依据。方法随机选择2012年1月至2018年2月行脾切除术患者63例,其中术后无门静脉血栓30例,术后有门静脉血栓33例。对术后血栓及术后无血栓者应用统计学方法分析其相关因素,如术前术后门脉直径、门脉流速差、脾容积、术中出血量、手术时间、体质指数等,应用多元回归筛选术后门脉系统血栓形成的相关危险因素。结果 63例患者中,脾切除断流术后未发生门脉系统血栓30例(47.62%);发生门脉系统血栓33例(52.38%),均于术后1～6个月内发生。术后血栓及术后无血栓者脾脏容积、脾切除前后门脉流速差、术前及术后门脉直径比较,差异有统计学意义(P<0.05)。经多因素Logistic回归分析,得出术前术后门脉流速差是脾切除术后门脉系统血栓形成的独立危险因素(P<0.05),而术前及术后门脉血流速度、手术时间、术中出血量以及体质指数与门脉血栓形成无关(P>0.05)。结论脾切除术后门脉系统血栓形成的危险因素较多,术前及术后门脉流速差是术后血栓形成的独立高危因素。针对不同患者给予个性化治疗能够预防门脉血栓的形成,减少脾切除术后出血的风险,有助于患者恢复。

体重低于6kg肝移植受者活体供肝的选择

在儿童肝移植领域中,有时外科医生在供肝处理时必须减少左外叶的体积,防止由于术后供肝体积过大所致的一系列并发症的发生。减少左外叶体积的方法有两种:使用S2段肝脏和减体积左外叶,但并没有建立供肝选择的规范。来自日本Jichi医科大学的学者进行了一项研究,对该中心体重小于6 kg的儿童活体肝移植受者的供肝选择方案进行了回顾性分析。

Efficacy of different treatment strategies for hepatocellular carcinoma with portal vein tumor thrombosis

AIM: To evaluate the efficacy of different treatment strategies for hepatocellular carcinoma (HCC) with portal vein tumor thrombosis (PVTT) and investigate factors influencing prognosis.METHODS: One hundred and seventy-nine HCC patients with macroscopic PVTT were enrolled in this study. They were divided into four groups and underwent different treatments: conservative treatment group (n = 18),chemotherapy group (n = 53), surgical resection group (n = 24) and surgical resection with postoperative chemotherapy group (n = 84). Survival rates of the patients were analyzed by the Kaplan-Meier method. A log-rank analysis was performed to identify group differences. Cox's proportional hazards model was used to analyze variables associated with survival.RESULTS: The mean survival periods of the patients in four groups were 3.6, 7.3, 10.1, and 15.1 mo respectively.There were significant differences in the survival rates among the groups. The survival rates at 0.5-, 1-, 2-, and 3-year in surgical resection with postoperative chemotherapy group were 55.8%, 39.3%, 30.4%, and 15.6% respectively, which were significantly higher than those of other groups (P＜0.001). Multivariate analysis revealed that the strategy of treatment (P＜0.001) and the number of chemotherapy cycles (P = 0.012) were independent survival predictors for patients with HCC and PVTT.CONCLUSION: Surgical resection of HCC and PVTT combined with postoperative chemotherapy or chemoembolization is the most effective therapeutic strategy for the patients who can tolerate operation.Multiple chemotherapeutic courses should be given postoperatively to the patients with good hepatic function reserve.

Portal vein thrombosis: Etiology and clinical outcome of cirrhosis and malignancy-related non-cirrhotic, non-tumoral extrahepatic portal venous obstruction

The etiology and pathogenesis of portal vein thrombosis are unclear. Portal venous thrombosis presentation differs in cirrhotic and tumor-related versus non-cirrhotic and non-tumoral extrahepatic portal venous obstruction (EHPVO). Non-cirrhotic and non-tumoral EHPVO patients are young and present with well tolerated bleeding. Cirrhosis and tumor-related portal vein thrombosis patients are older and have a grim prognosis. Among the 118 patients with portal vein thrombosis, 15.3% had cirrhosis, 42.4% had liver malignancy (primary or metastatic), 6% had pancreatitis (acute or chronic), 5% had hypercoagulable state and 31.3% had idiopathy, 12% had hypercoagulable state in the EHPVO group.

Portal hypertension due to portal venous thrombosis:Etiology, clinical outcomes

The thrombophilia in adult life has major implications in the hepatic vessels. The resulting portal vein thrombosis has various outcomes and complications. Esophageal varices, portal gastropathy, ascites, severe hypersplenism and liver failure needing liver transplantation are known well. The newly formed collateral venous circulation showing itself as pseudocholangicarcinoma sign and its possible clinical reflection as cholestasis are also known from a long time. The management strategies for these complications of portal vein thrombosis are not different from their counterpart which is cirrhotic portal hypertension, but the prognosis is unquestionably better in former cases. In this review we present and discuss the portal vein thrombosis, etiology and the resulting dinical pictures. There are controversial issues in nomenclature, management （including anticoagulation problems）, follow up strategies and liver transplantation. In the light of the current knowledge, we discuss some controversial issues in literature and present our experience and our proposals about this group of patients.

Percutaneous electrochemotherapy in the treatment of portal vein tumor thrombosis at hepatic hilum in patients with hepatocellular carcinoma in cirrhosis: A feasibility study

AIMTo treated with electrochemotherapy (ECT) a prospective case series of patients with liver cirrhosis and Vp3-Vp4- portal vein tumor thrombus (PVTT) from hepatocellular carcinoma (HCC), in order to evaluate the feasibility, safety and efficacy of this new non thermal ablative technique in those patients.METHODSSix patients (5 males and 1 female), aged 61-85 years (mean age, 70 years), four in Child-Pugh A and two in Child-Pugh B class, entered our study series. All patients were studied with three-phase computed tomography (CT), contrast enhanced ultrasound (CEUS) and ultrasound-guided percutaneous biopsy of the thrombus before ECT. All patients underwent ECT treatment (Cliniporator Vitae®, IGEA SpA, Carpi, Modena, Italy) of Vp3-Vp4 PVTT in a single session. At the end of the procedure a post-treatment biopsy of the thrombus was performed. Scheduled follow-up in all patients entailed: CEUS within 24 h after treatment; triphasic contrast-enhanced CT and CEUS at 3 mo after treatment and every six months thereafter.RESULTSPost-treatment CEUS showed complete absence of enhancement of the treated thrombus in all cases. Post-treatment biopsy showed apoptosis and necrosis of tumor cells in all cases. The follow-up ranged from 9 to 20 mo (median, 14 mo). In 2 patients, the follow-up CT and CEUS demonstrated complete patency of the treated portal vein. Other 3 patients showed a persistent avascular non-tumoral shrinked thrombus at CEUS and CT during follow-up. No local recurrence was observed at follow-up CT and CEUS in 5/6 patients. One patient was lost to follow-up because of death from gastrointestinal hemorrage 5 wk after ECT.CONCLUSIONIn patients with cirrhosis, ECT seems effective and safe for curative treatment of Vp3-Vp4 PVTT from HCC.

Evaluation and management of patients with refractory ascites

Some patients with ascites due to liver cirrhosis become no longer responsive to diuretics. Once other causes of ascites such as portal vein thrombosis, malignancy or infection and non-compliance with medications and low sodium diet have been excluded, the diagnosis of refractory ascites can be made based on strict criteria. Patients with refractory ascites have very poor prognosis and therefore referral for consideration for liver transplantation should be initiated. Search for reversible components of the underlying liver pathology should be undertaken and targeted therapy, when available, should be considered. Currently, serial large volume paracentesis （LVP） and transjugular intrahepatic portasystemic stent-shunt （TIPS） are the two mainstay treatment options for refractory ascites. Other treatment options are available but not widely used either because they carry high morlJidity and mortality （most surgical options） rates, or are new interventions that have shown promise but still need further evaluation. In this comprehensive review, we describe the evaluation and management of patients with refractory ascites from the prospective of the practicing physician.

Combined endovascular brachytherapy, sorafenib, and transarterial chemobolization therapy for hepatocellular carcinoma patients with portal vein tumor thrombus

AIM To evaluate the safety and efficacy of combined endovascular brachytherapy(EVBT),transarterial chemoembolization(TACE),and sorafenib to treat hepatocellular carcinoma(HCC) patients with main portal vein tumor thrombus(MPVTT).METHODS This single-center retrospective study involved 68 patients with unresectable HCC or those who were unfit for liver transplantation and percutaneous frequency ablation according to the BCLC classification. All patients had Child-Pugh classification grade A or B,Eastern Cooperative Oncology Group(ECOG)performance status of 0-2,and MPVTT. The patients received either EVBT with stent placement,TACE,and sorafenib(group A,n = 37),or TACE with sorafenib(group B,n = 31). The time to progression(TTP) and overall survival(OS) were evaluated by propensity score analysis.RESULTS In the entire cohort,the 6-,12-,and 24-mo survival rates were 88.9%,54.3%,and 14.1% in group A,and 45.8%,0%,and 0% in group B,respectively(P < 0.001). The median TTP and OS were significantly longer in group A than group B(TTP: 9.0 mo vs 3.4 mo,P < 0.001; OS: 12.3 mo vs 5.2 mo,P < 0.001). In the propensity score-matched cohort,the median OS was longer in group A than in group B(10.3 mo vs 6.0 mo,P < 0.001). Similarly,the median TTP was longer in group A than in group B(9.0 mo vs 3.4 mo,P < 0.001). Multivariate Cox analysis revealed that the EVBT combined with stent placement,TACE,and sorafenib strategy was an independent predictor of favorable OS(HR = 0.18,P < 0.001). CONCLUSION EVBT combined with stent placement,TACE,and sorafenib might be a safe and effective palliative treatment option for MPVTT.

Highly metabolic thrombus of the portal vein:^(18)F fluorodeoxyglucose positron emission tomography/computer tomography demonstration and clinical significance in hepatocellular carcinoma

AIM： To assess the ability of ^18F-fluorodeoxyglucose positron emission tomography/computer tomography （^18F-FDG PET/CT） to differentiate between benign and malignant portal vein thrombosis in hepatocellular carcinoma （HCC） patients.METHODS： Five consecutive patients who had HBV cirrhosis, biopsy-proven HCC, and thrombosis of the main portal vein and/or left/right portal vein on ultrasound （US）, computer tomography （CT） or magnetic resonance imaging （MRI） were studied with ^18F-FDG PET/CT. The presence or absence of a highly metabolic thrombus on ^18F-FDG PET/CT was considered diagnostic for malignant or benign portal vein thrombosis, respectively. All patients were followed-up monthly with US, CT or MRI. Shrinkage of the thrombus or recanalization of the vessels on US, CT or MRI during follow-up was considered to be definitive evidence of the benign nature of the thrombosis, whereas enlargement of the thrombus, disruption of the vessel wall, and parenchymal infiltration over follow-up were considered to be consistent with malignancy. ^18SF-FDG PET/CT, and US, CT or MRI results were compared.RESULTS： Follow-up （1 to 10 mo） showed signs of malignant thrombosis in 4 of the 5 patients. US, CT or MRI produced a true-positive result for malignancy in 4 of the patients, and a false-positive result in 1. ^18F-FDG PET/CT showed a highly metabolic thrombus in 4 of the 5 patients. ^18F-FDG PET/CT achieved a true-positive result in all 4 of these patients, and a true-negative result in the other patient. No false-positive result was observed using ^18F-FDG PET/CT.CONCLUSION： ^18F-FDG PET/CT may be helpful in discriminating between benign and malignant portal vein thrombi. Patients may benefit from ^18F-FDG PET/CT when portal vein thrombi can not be diagnosed exactly by US, CT or MRI.

Contrast-enhanced sonography versus biopsy for the differential diagnosis of thrombosis in hepatocellular carcinoma patients

AIM:To clarify which method has accuracy:2nd gen-eration contrast-enhanced ultrasound or biopsy of portal vein thrombus in the differential diagnosis of portal vein thrombosis.METHODS:One hundred and eighty-six patients with hepatocellular carcinoma and portal vein thrombosis underwent in blinded fashion a 2nd generation contrast-enhanced ultrasound and biopsy of portal vein thrombus;both results were examined on the basis of the follow-up of patients compared to reference-standard.RESULTS:One hundred and eight patients completed the study.Benign thrombosis on 2nd generation contrast-enhanced ultrasound was characterised by progressive hypoenhancing of the thrombus;in malignant portal vein thrombosis there was a precocious homo-geneous enhancement of the thrombus.On follow-up there were 50 of 108 patients with benign thrombosis:all were correctly diagnosed by both methods.There were 58 of 108 patients with malignant thrombosis:amongst these,52 were correctly diagnosed by both methods,the remainder did not present malignant cells on portal vein thrombus biopsy and showed on 2nd generation contrast-enhanced ultrasound an inho-mogeneous enhancement pattern.A new biopsy during the follow-up,guided to the area of thrombus that showed up on 2nd generation contrast-enhanced ultra-sound,demonstrated an enhancing pattern indicating malignant cells.CONCLUSION:In patients with hepatocellular carcinoma complicated by portal vein thrombosis,2nd generation contrast-enhanced ultrasound of portal vein thrombus is very useful in assessing the benign or malignant nature of the thrombus.Puncture biopsy of thrombus is usually accurate but presents some sampling errors,so,when pathological results are required,2nd generation contrast-enhanced ultrasound could guide the sampling needle to the correct area of the thrombus.