【摘要】 目的观察脾腔小口径分流联合断流术对肝硬化门静脉高压症患者肝血流动力学和肝储备功能的影响。方法 86例肝硬化门静脉高压症患者,分别行脾腔小口径分流联合断流术(联合组,58例)和贲门周围血管离断术(断流组,28例)。通过术中自由门静脉压力(FPP)监测和术后彩色多普勒超声检查明确不同手术方式对门静脉血流量(PVF)的影响,通过吲跺氰绿排泄试验(ICGR15)观察肝储备功能和有效肝血流量(FHF)的变化。结果联合组术后FPP、PVF、FHF和ICGR15分别为(31.4±2.4)cm H2O、(900±350)ml/min、(551±246)ml/min和(31.2±13.8)%,较术前有明显降低或升高【(38.2±3.6)cm H2O、(1250±360)ml/min、(696±300)ml/min和(23.6±11.9)%,P<0.05】。断流组术后FPP、PVF,FHF和ICGR15为(32.8±3.2)cm H2O、(980±250)ml/min、(507±140)ml/min和(27.4±13.0)%,也较术前明显升高或降低【(36.9±3.9)cm H2O、(1320±320)ml/min)、625±158)ml/min和(22.2±13.4)%,P<0.05】。与断流组比较,联合组FPP下降更为明显(P<0.05),而PVF、FHF和ICGR15比较无显著性差异(P>0.05)。术后30天联合组肝功能良好、轻度和重度代偿不全发生率为72.4%、19.0%和8.6%,断流组分别为67.9%、21.4%和10.7%,两者差异无显著统计学意义。随访5~36月,联合组分别有1例和4例发生上消化道出血和肝性脑病,断流组分别为3例和2例。结论脾腔小口径分流联合断流术治疗门静脉高压症是安全有效的,该术式在降低门静脉压力同时,可维持门静脉向肝血流,保护肝脏储备功能,防止肝功恶化衰竭。更多还原

【Abstract】 Objective To evaluate the effects of the small diameter splenocaval shunt plus devascularization procedure on changes to hepatic hemodynamics and functional reserve in patients with portal hypertension. Methods Clinical data of 86 patients(58 underwent shunt plus devascularization procedure and 28 received devascularization procedure only) with portal hypertension of cirrhosis from Aug 2010 to Jul 2013 were analyzed retrospectively. Portal vein hemodynamics was studied by monitoring the free portal pressure(FPP)intra-operatively and color Doppler flow imaging. Hepatic functional reserve was estimated by the indo-cyanine green retention ratio at fifteen minutes(ICGR15) and the functional hepatic flow(FHF). Clinical effects were followed-up and compared between two groups. Results In combinational therapy group,the postoperative FPP,portal venous flow(PVF),FHF and ICGR15 were(31.4±2.4)cm H2 O,(900 ±350) ml/min,(551 ±246) ml/min and(31.2±13.8)%,respectively,which were significantly different from those before operation [(38.2±3.6) cm H2 O,(1250±360) ml/min,(696±300) ml/min and(23.6±11.9)%,P<0.05]. In devascularization group,the postoperative FPP,portal venous flow(PVF),FHF and ICGR15 were(32.8±3.2) cm H2 O,(980±250) ml/min,(507±140) ml/min and(27.4±13.0)%,respectively,which also different from those before operation [(36.9±3.9) cm H2 O,(1320±320)ml/min,(625±158) ml/min and(22.2±13.4)%,(P<0.05)]. Compared to the devascularization group,the decrease of FPP in combinational therapy group was greater(P <0.05),however,there were no differences in PVF,FHF and ICGR15 between the two groups. There were four(1 in combinational therapy and 3 in devascularization group)and 3 patients(2 in combinational therapy and 1 in devascularization group) experienced re-hemorrhage and encephalopathy,respectively,during postoperative follow-up. Conclusion Changes in the hemodynamics are sensible because the combined procedure would not only decrease the FPP but also maintain the portal flow to the liver,sustain the hepatic reserve and protect the liver function from the risk of liver failure. This indicates that the small diameter splenocaval shunt plus devascularization procedure is safe and effective for the treatment of portal hypertension.更多还原