【作者】 张鹏；

【导师】 王禹；

【作者基本信息】 吉林大学 ， 临床医学硕士（专业学位）， 2018， 硕士

【摘要】 目的:通过对腹腔镜脾切除术(Laparoscopic splenectomy,LS)和开腹脾切除术(Open splenectomy,OS)在治疗门脉高压所致脾亢的两组临床病例资料进行收集、整理、统计;比较分析腹腔镜脾切除术与开腹手术在治疗门脉高压症脾亢中的临床应用差异,为临床腹腔镜手术治疗门脉高压症脾亢提供一定的指导意义。方法:收集2014年1月到2017年12月间在吉林大学第二医院确诊为肝炎性肝硬化、门脉高压症所致脾亢需行脾脏切除术59例病人的临床资料,其中开腹手术30例,腹腔镜手术29例,因术中难以控制的大出血中转开腹2例予以去除,其余27例均获成功。收集相关资料如肝炎类型、肝功能分级、脾脏大小、手术时间、术后并发症等。对两组在术前、围手术期、术后并发症、费用等方面的情况进行统计分析。结果:腹腔镜组(LS组)27例,其中男性16例,女性11例;年龄(51.96士6.54)岁,开腹组(OS组)30例,其中男性18例,女性12例;年龄(52.43士6.43)岁;腹腔镜组(LS组)肝硬化类型:乙肝肝硬化26例,丙肝肝硬化1例,术前肝功能Child-Pugh分级:A级15例,B级12例;开腹组(OS组)肝硬化类型:乙肝肝硬化26例,丙肝肝硬化4例;术前肝功能Child分级:A级15例,B级15例。LS组与OS组相比,脾长径分别为(16.84±1.37)cm和(17.04±1.60)cm(P=0.611);平均手术时间分别为(210.56士33.41)min和(124.00士28.99)min(P<0.001);术中出血量分别为(249.63士51.25)ml和(471.00士152.07)ml(P<0.001);平均住院时间分别为7.00(7.00,9.00)天和13.50(10.00,16.00)天(P<0.001);术后排气时间分别为3.00(3.00,4.00)天和5.00(3.00,5.00)天(P=0.003);术后拔除引流管时间分别为6.00(5.00,7.00)天和10.00(7.75,10.00)天(P<0.001);住院费用分别为(73609.48士5502.674)元和(64807.62士10860.206)元(P=0.015);LS组术后有1例并发胸腔积液、l例门脉血栓,总并发症发生率7.4%;OS组4例并发胸/腹腔积液、3例肺部感染、2例切口感染、1例门脉血栓、1例脾热,总并发症发生率36.7%(P=0.009)。结论:1、通过分析LS与OS在门静脉高压症脾功能亢进中的治疗效果,发现LS住院费用高、手术时间长,但术中失血量较少、术后并发症少、术后胃肠动力恢复较快、平均住院日较短等优点;2、LS是一种较复杂的术式,手术级别高,不仅要求术者腹腔镜手术经验丰富,而且对腹腔镜设备要求也很高;随着术者腹腔镜手术经验的积累以及手术器械的革新,LS住院费用会逐渐降低、手术时间逐渐缩短;3、腹腔镜脾切除术是安全、有效、可行的。在经验丰富的中心并熟练掌握腔镜技术的条件下可以推广开展。更多还原

【Abstract】 Objective: The clinical data of two groups of patients with hypersplenism caused by portal hypertension were collected,sorted and counted by laparoscopic splenectomy and open splenectomy.To compare and analyze the difference of clinical application between laparoscopic splenectomy and open surgery in the treatment of hypersplenism of portal hypertension,and to provide certain guiding significance for clinical laparoscopic surgery in the treatment of hypersplenism of portal hypertension.Methods: From January 2014 to December 2017,a total of 59 patients with the diagnosis of liver cirrhosis,portal hypertension and hyperspleenism underwent spleenectomy in the Second Hospital of Jilin University.Out of 59 patients,30 received open spleenectomy whereas remaining 29 patients received laparoscopic spleenectomy.Laparotomy was performed in 2 of those laparoscopic splenectomy patients because of uncontrolled haemorrhage.Relevant data of each patient such as type of hepatitis,liver function tests,size of spleen,operation time,post operative complications,operation cost was collected and analyzed statistically.Results: Of the analyzed 27 cases who received laparoscopic splenectomy(LS),there was 16 male and 11 female patients with the median age of 51.96±6.43 years.26 patients had hepatitis B induced liver cirrhosis,1 patient had hepatitis C induced liver cirrhosis.15 patients were classified as Child-Pugh A and 12 patients were Child-Pugh B.In the operative splenectomy(OS)group,18 were male and 12 were female with the median age of 52.43±6.43 years.26 patients had hepatitis B induced liver cirrhosis,4 had hepatitis C induced cirrhosis.15 were classified as child-pugh A and 15 were classified as child-pugh B.The diameter of the spleen was 16.84±1.37 cm in LS group while it was 17.04±1.60 cm in the operative group(p=0.611)respectively.The average operative time was 210.56 ± 33.41 min in the LS group whereas it was 124.00 ± 28.99 min in OS group(p<0.001)respectively.the intraoperative bleeding volume was 249.63 ± 51.25 ml in the LS group whereas it was 471.00 ± 152.07 ml in OS group(p<0.001)respectively.The overall hospital stay was 7 days(7-9)in LS group vs 13.5 days(10-16)in OS group(p<0.001)respectively.Postoperative gastrointestinal function recovery time was 3(3-4)days in LS group whereas it was 5(3-5)days in OS group(p=0.003).The drain was removed in 6(5-7)days in LS group where as it was removed in 10(7.75-10)days in OS group(p<0.001).The total cost from the time of admission to discharge was 73609.48 ± 5502.674 yuan in LS group and 64807.62 ± 10860.206 yuan in OS group(P=0.015).In postoperative period,1 patient had pleural effusion and 1 patient had portal veous thrombosis in LS group with complication rate of 7.4%.In OS group,4 patients had pleural and peritoneal effusion,3 had pulmonary infection,1 had portal venous thrombosis and 1 had splenic fever with total complication rate of 36.7%(p=0.009).Conclusion: 1.Higher hospitalization cost and Longer operation time were noted in case of laparoscopic surgery group than operative surgery group but there was less intraoperative bleeding,earlier recovery of gastrointestinal function,shorter duration of hospital stay as well as lower incidence of complications in laparoscopic surgery group;2.Laparoscopic splenectomy is a complicated procedure with high grade,so surgeons need to be very experience to perform laparoscopic splenectomy.With the innovation of new equipments,surgeons also need to be more innovative.More and more splenectomy should be performed in carefully selected cases which will eventually help to shorten the operative time;3.Laparoscopic splenectomy is effective,safe and feasible.Laparoscopic splenectomy will gradually shorten the operation time and reduce the cost of hospitalization with the help of new instruments,good techniques and with the use in carefully selected cases in good and well established centers.更多还原