Combined splenocaval or mesocaval C shunt and portoazygous devascularization in the treatment of portal hypertension: analysis of 150 cases

BACKGROUND: Portal hypertension is a common disease and its major surgical therapeutic approaches include devascularization and shunting. This study was undertaken to investigate the effects of combined splenocaval or mesocaval C shunt and portoazygous devascularization (combined procedures) on portal hypertension. METHODS: The clinical data of 150 patients with portal hypertension who had undergone combined procedures at the First Affiliated Hospital of Zhengzhou University from May1990 to May 2003 were analyzed retrospectively. RESULTS: The mean free portal pressure (FPP) was 25.6±1.83 mmHg, 18.0±2.07 mmHg and 18.4±2.19 mmHg before operation, after splenectomy plus splenocaval or mesocaval C shunt, and combined procedures, respectively. There was no operative death in all patients. The 1-7 year follow-up of 100 patients showed rebleeding in 3 patients, encephalopathy in 4, thrombosis of artificial vascular graft in 3, and dying from liver failure in 2. CONCLUSIONS: The combined procedures can not only decrease portal pressure but also preserve hepatic blood flow to some extent. It may be one of the best choices for treating portal hypertension in China.

Small-diameter prosthetic H-graft portacaval shunts in the treatment of portal hypertension

Background Portasystemic shunts, especially total shunts, are effective tools for reducing portal pressure and controlling variceal bleeding but lead to high risk of encephalopathy and accelerating liver failure. The purpose of this study is to evaluate the clinical effects of small-diameter expanded polytetrafluoroethylene (ePTFE ) H-graft portacaval shunts in the treatment of portal hypertension.Methods Thirty-one patients with portal hypertension were treated with ePTFE small-diameter H-graft portacaval shunts from December 1995 to April 2002. Twenty-one had externally ringed grafts and 10 had non-ringed grafts; 20 had 10 mm diameter grafts and 11 had 8 mm grafts. The left gastric artery and coronary vein were ligated in 22 patients. Additionally, 6 patients underwent pericardial devascularization, and splenectomies were performed on 30 patients.Results An average decrease of free portal pressure (FPP) from (32. 13 ±4. 86) cmH2O before shunting to (12. 55 ±5. 57) cmH2O after shunting was observed. Portal blood flow was reduced by 1/3 compared with the levels measured before shunting. Twenty-eight patients survived after the operation, and no upper gastrointestinal rebleeding occurred in the follow-up period (40. 2 months on average). We lost contact with one patient. Color Doppler ultrasonography and/or portography revealed the shunts to be patent in 28 cases and occluded in 2 (6. 4%) cases. Encephalopathy developed in 4 patients (12. 9%).Conclusion Small-diameter ePTFE H-graft portacaval shunts can effectively reduce portal pressure. Moreover, the majority of the hepatopetal flow from the portal vein can be adequately maintained. The reinforced shunts may achieve a higher rate of patency. Morbidity from encephalopathy was less frequent than in pateints receiving total shunts. Small-diameter H-graft portacaval shunts are also effective in preventing recurrent variceal bleeding.

Partial portacaval shunt with H-grafts to treat portal hypertension

Partial portosystemic shunts have been popularized because of a reported low rate of mortality and morbidity(especially encephalopathy,liver failure and occlusion).The results of partial portacaval shunts[small-diameter expanded polytetrafluoroethylene(ePTFE)H-graft portacaval shunt]were retrospectively reviewed to evaluate the clinical efficacy in the treatment of portal hypertension.Forty-three patients with portal hypertension were treated by small-diameter H-graft of ePTFE portacaval shunt from May 1995 to April 2006.Thirty-three had externally ringed grafts and ten had non-ringed ones.Ten had grafts of 10 mm in diameter and 33 had grafts of 8 mm.The left gastric artery and coronary vein were ligated in all the cases.Six had pericardial devascularization and splenectomy was performed in 42.An average decrease of free portal pressure(FPP)from(33.24 P4.78)cmH2O before shunting and(13.65P5.65)cmH2O after shunting was observed.The portal blood flow was reduced by one-third of that before shunt.Thirty-eight patients survived and no upper gastro-intestinal rebleeding occurred in the follow-up period(50.5 months in average).Two were out of contact.Color Doppler ultrasonography and/or portography revealed the shunts were patent in 38 cases and were occluded in three cases(3/41,7.3%).Encephalopathy developed in five cases(5/41,12.2%).Partial(small-diameter ePTFE H-graft)portacaval shunting can reduce the portal pressure effectively.Majority of the hepatic flow from the portal vein can be maintained adequately.The shunts with reinforced grafts can keep a higher rate of patency.The morbidity of encephalopathy was lower than those with total shunt.The partial portacaval shunt is effective in preventing recurrent variceal bleeding.

应用PTFE人造血管行门腔H型吻合治疗门静脉高压症

目的 了解血管移植物PTFE在H型门腔分流道的通畅率,分流口径对向肝血流的影响以及减压效果和并发症。方法 用内径10mm普通型PTFE和带支撑环的PTFE分别为12例及8例肝硬化门静脉高压症患者进行了门腔静脉间的H型分流术。其中肝功能ChildA级13例,B级5例,C级2例。平均年龄434岁。结果 无手术死亡。术后平均随访172个月,脑病Ⅰ～Ⅱ级2例,无曲张静脉破裂再出血。术后门脉系统彩色多普勒超声及血管造影检查,向肝血流量无明显影响,分流道通畅率90%。普通PTFE者血栓形成2例(167%);带支撑环PTFE者无血栓形成。结论 该技术在减低门静脉压力,维持向肝血流,预防再出血等方面均取得了良好结果,其中带支撑环者优于普通型。

小口径人造血管门腔静脉H型分流治疗门静脉高压症

目的 评价小口径人造血管门腔静脉 H型分流治疗门脉高压症的临床效果。方法 1995年 11月～ 1999年 9月采用小口径 e PTFE(膨化聚四氟乙烯 )人造血管门腔静脉 H型分流治疗 2 3例门静脉高压症患者 ,同时行胃左动脉及冠状静脉结扎 ,2 2例同时切除脾脏。结果 自由门脉压平均由分流前 31.2 7± 4.71cm H2 O降至分流后 16 .82± 3.2 8cm H2 O,门脉向肝血流量较术前减少约 1/ 3。平均随访 2 0 .2月 ,2 3例全部存活 ,均未发生消化道再出血 ,彩超和 /或下腔静脉造影检查示 2 1例分流道通畅 ,2例闭塞 (8.7% ) ,3例发生肝性脑病 (13% )。结论 小口径 e PTFE人造血管门腔静脉 H型分流能有效的降低门脉压力 ,亦能维持大部分门脉向肝血流 ,肝性脑病发生率较低 ,带支持环者通畅率高 ,疗效确切。

肠腔静脉人工血管C型分流术的远期疗效观察

目的探讨肠腔静脉C型分流术治疗食管胃底静脉曲张破裂出血的远期疗效。方法对咸阳市中心医院肝胆外科1992年以来施行的36例肠腔静脉C型分流术的临床资料进行总结分析。结果36例患者术后门静脉压平均下降1.51kPa,胃镜检查食管静脉曲张均有明显减轻或消失。术后再出血率5.6%,肝性脑病发生率8.3%,术后1年、3年、5年及10年的生存率分别为97.2%、93.3%、89.3%及66.7%。结论肠腔静脉C型分流术手术适应证广,操作简单,近、远期疗效满意,适于推广。

门腔静脉人工血管搭桥分流术治疗门静脉高压症

目的观察用门腔静脉间人工血管搭桥分流术治疗门静脉高压症患者的临床疗效，并与传统的门体分流术比较。方法采用带外支撑环的８ｍｍ口径聚四氟乙烯（ＧｏｒｅＴｅｘ）薄壁人工血管行门腔静脉间搭桥分流术，所用人工血管长度为２～３ｃｍ，共治疗２０例患者。结果搭桥分流术后门静脉压力下降幅度与同期１７例脾肾静脉分流术及１１例门腔静脉侧侧分流术相比差异无显著意义（０８３±０３１ｋＰａ，０８１±０５０ｋＰａ及１０２±０４５ｋＰａ，Ｐ＞００５）。三组患者全部获得随访，平均随访时间为１５～２８个月，手术死亡率及再出血率没有差别，但搭桥分流组术后脑病发生率显著低于门腔侧侧分流组（５０％及３６４％，Ｐ＜００５）。２０例患者术后近期均经下腔静脉行门静脉造影，人工血管通畅率为９５％，出院后１９例患者均经一次以上Ｂ超检查，随访已超过１５个月，人工血管均通畅。结论门腔静脉间小口径人工血管搭桥分流术对患者创伤小，操作简便，术后脑病发生率低。

脾肾静脉间置人造血管分流术7例报告

目的 探讨脾肾静脉间置人造血管分流术治疗门静脉高压症的可行性。方法 自 1999年 1～ 12月施行脾肾静脉间置人造血管 (PTFE)的脾肾静脉分流术治疗门静脉高压症 7例并进行随访。结果 分流后门脉压力平均下降 1 2 7kPa,无并发症及手术死亡。随访 5～ 12个月 ,彩超示间置人造血管通畅 ,食道吞钡显示食道静脉曲张改善 4例 ,消失 3例。无再出血 ,无肝性脑病。结论 该术式治疗门静脉高压症较传统手术简单安全 ,疗效确切。

小口径人工血管架桥门体分流联合贲门周围血管离断术治疗门静脉高压症上消化道出血

目的探讨小口径人工血管（直径0．8cm）门体静脉架桥联合贲门周围血管离断术在门静脉高压症（PHT）合并上消化道出血治疗中的应用价值。方法对38例PHT合并上消化道出血患者采用小口径人工血管脾一腔架桥（14例）、肠-腔架桥（24例）联合贲门周围血管离断术治疗。结果术后患者自由门静脉压力平均下降（6．6±1．2）cm H2O，手术前后肝功能相比差异无统计学意义（P〉0．05）。脾-腔架桥组术后外周血血小板和白细胞计数恢复正常（均P〈0．05）。手术死亡率为3％。术后并发症有发热4例，顽固性腹水和乳糜腹水各1例，肝性脑病1例，腹腔感染1例，应激性溃疡1例。除1例腹腔感染患者死亡外，其余经保守治疗后均痊愈。对35例进行了6个月至3年的随访，消化道出血复发2例，死亡2例，总有效率为89％。1年和3年人工血管通畅率分别为80％和75％。25例患者于术后6个月行纤维胃镜检查，食管胃底静脉曲张基本消失或减轻。结论小口径人工血管架桥门体分流联合贲门周围血管离断术治疗PHT合并上消化道出血可明显降低门静脉压力，有效控制上消化道出血，肝性脑病发生率低。脾一腔架桥术可同时消除患者脾脏功能亢进。

脾大部切除脾肾静脉人造血管架桥术治疗门静脉高压症

目的探讨一种新手术方法,即脾大部切除脾肾静脉人造血管架桥术治疗门静脉高压症的治疗效果。方法脾大部切除后以人造血管行脾肾静脉架桥术9例。先行保留脾上段的脾大部切除术,再行脾肾静脉人造血管架桥,最后行贲门周围血管离断。结果 1例术后2天因肝功能衰竭、创面渗血不止死亡,其余无脾断面出血、感染。无近期出血。本组病例获随访1～3年,无复发出血,经血液学(IgG、IgM、IgA)、B 超、CT、^(99m)锝扫描等证实:脾脏不同程度缩小,脾功能亢进缓解,残脾有免疫功能。Doppler彩色超声显像:人造血管血流通畅,无逆流现象。结论该术式既可解决门静脉高压症脾功能亢进问题,又能起到降压效果。