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《中华消化外科杂志》2018年10月第17卷第10期论著

贲门周围血管离断联合脾切除及胃底部分切除术治疗肝硬化门静脉高压症胃底静脉重度曲张伴胃肾分流的临床疗效

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严茂林,吴嘉艺,魏少明,等.贲门周围血管离断联合脾切除及胃底部分切除术治疗肝硬化门静脉高压症胃底静脉重度曲张伴胃肾分流的临床疗效[J].中华消化外科杂志,2018,17(10):1024-1029.DOI:10.3760/cma.j.issn.1673-9752.2018.10.011.
【摘要】

目的:探讨贲门周围血管离断联合脾切除及胃底部分切除术治疗肝硬化门静脉高压症胃底静脉重度曲张伴胃肾分流的临床疗效。
方法:采用回顾性横断面研究方法。收集2010年1月至2015年12月福建省立医院收治的18例肝硬化门静脉高压症胃底静脉重度曲张伴胃肾分流患者的临床病理资料。根据技术开展阶段,结合患者及家属意愿选择行开腹或腹腔镜手术,行贲门周围血管离断联合脾切除及胃底部分切除术。观察指标:(1)手术及术后恢复情况。(2)术后病理学检查情况。(3)随访和生存情况。采用门诊和电话方式进行随访。术后1个月复查胃镜、腹上区X线计算机体层摄影术(CT)增强扫描或磁共振成像(MRI),了解胃底曲张静脉切除情况。术后1年内每3个月随访1次,1年后每半年随访1次,了解患者术后远期并发症发生情况和生存情况。随访时间截至2017年6月。正态分布的计量资料以±s表示,偏态分布的计量资料以M(范围)表示。采用Kaplan-Meier法计算患者生存率。
结果:(1)手术及术后恢复情况:18例患者均顺利完成贲门周围血管离断联合脾切除及胃底部分切除术,其中12例行开腹手术,6例行腹腔镜手术(其中1例因术中发生不可控制的出血中转开腹手术、5例完成腹腔镜手术)。无围术期死亡患者。12例开腹手术患者手术时间为(192±20)min,术中出血量为(280±30)mL,无术中输血患者,术后胃肠功能恢复时间为(33±6)h,术后引流管拔除时间为8 d(5~9 d);术后发生胸腔积液7例、胃排空延迟1例,予保守治疗后痊愈;术后住院时间为8 d(5~12 d)。6例腹腔镜手术患者手术时间为(208± 40)min,术中出血量为(210±10)mL,术中1例患者输浓缩红细胞2 U,术后胃肠功能恢复时间为(28±5)h,术后引流管拔除时间为7 d(5~26 d);术后发生胸腔积液4例、胃排空延迟1例、A级胰漏1例,予保守治疗后痊愈;术后住院时间为7 d(5~10 d)。(2)术后病理学检查情况:18例患者术后病理学检查结果示胃底黏膜下和浆膜见大量曲张静脉;中重度肝硬化。(3)随访和生存情况:18例患者均获得术后随访,随访时间为8~78个月,中位随访时间为39个月。术后1个月复查胃镜和CT增强扫描结果示:胃底均未见曲张静脉。随访期间,18例患者无胃底静脉曲张伴胃肾分流复发及食管狭窄等并发症发生。4例患者发生门静脉血栓,其中1例患者因自行停服华法林,于术后8个月因门静脉高压性胃病再次发生上消化道出血死亡;其余3例经华法林抗凝等治疗后门静脉再通。1例患者于术后32个月发现肝癌,予射频消融术治疗。2例患者死亡,其中1例于术后35个月死于肝衰竭,1例于术后54个月死于晚期肝癌。18例患者术后1、3、5年总体生存率分别为93.8%、84.4%、70.3%。
结论:采用贲门周围血管离断联合脾切除及胃底部分切除术治疗肝硬化门静脉高压症胃底静脉重度曲张伴胃肾分流安全有效,对合适病例有推广价值。

【Abstract】

Objective:To investigate the clinical efficacy of pericardial devascularization (PCDV) combined with splenectomy and partial gastric fundus resection (PGFR) in the treatment of portal hypertensioninduced severe gastric varices complicated with gastrorenal shunt (GRS).
Methods:The retrospective crosssectional study was conducted. The clinicopathological data of 18 patients with portal hypertensioninduced severe gastric varices complicated with GRS who were admitted to the Fujian Provincial Hospital from January 2010 to December 2015 were collected. According to the stage of technical development, open surgery or laparoscopic surgery was selected based on patients′ and their family's wishes. Observation indicators: (1) surgical and postoperative recovery situations; (2) postoperative pathological examination; (3) followup and survival. The followup using outpatient examination and telephone interview was performed once every 3 months within 1 year postoperatively and once every 6 months after 1 year to detect longterm complications and survival up to June 2017. The reexaminations of gastroscopy, enhanced scan of X-ray computed tomography (CT) on the epigastric region or magnetic resonance imaging (MRI) were done at 1 month postoperatively for detecting resection of fundus ventriculi varicosity. Measurement data with normal distribution were represented as ±s. Measurement data with skewed distribution were described as M (range). The survival rate was calculated by the Kaplan-Meier method.
Results:(1) Surgical and postoperative recovery situations: 18 patients underwent successful PCDV combined with splenectomy and PGFR, including 12 with open surgery and 6 with laparoscopic surgery (1 with conversion to open surgery due to intraoperatively uncontrollable bleeding). There was no perioperative death. The operation time, volume of intraoperative blood loss, recovery time of gastrointestinal function, time of postoperative drainagetube removal and duration of hospital stay were (192±20)minutes, (280±30)mL, (33±6)hours, 8 days (range, 5-9 days), 8 days (range, 5-12 days) in 12 patients with open surgery and (208±40)minutes, (210±10)mL, (28±5)hours, 7 days (range, 5-26 days), 7 days (range, 5-10 days) in 6 patients with laparoscopic surgery, respectively. One patient with laparoscopic surgery had intraoperative condensed erythrocyte infusion with 2 U. Seven, 1, 0 patients with open surgery and 4, 1, 1 patients with laparoscopic surgery were respectively complicated with pleural effusion, delayed gastric emptying and pancreatic leakage in level A, and they were cured by conservative treatment. (2) Postoperative pathological examination: results of postoperative pathological examination in 18 patients showed that a large number of varicose veins in the mucous and serosal layers of gastric fundus and moderate or severe hepatic cirrhosis. (3) Followup and survival: 18 patients were followed up for 8-78 months with a median time of 39 months. The gastroscopy and enhanced scan of X-ray CT at 1 month postoperatively showed that no varicose veins in the gastric fundus. During the followup, there was no recurrence of gastric varices with GRS and esophageal stenosis. Of 4 patients with portal vein thrombosis, 1 died of portal hypertensive gastropathyinduced upper gastrointestinal bleeding due to stop taking warfarin, and other 3 patients had portal vein patency by warfarin therapy. One patient was complicated with liver cancer at 32 months postoperatively and received radiofrequency ablation therapy. Two patients died, including 1 dying of hepatic failure at 35 months postoperatively and 1 dying of advanced liver cancer at 54 months postoperatively. The 1, 3 and 5year overall survival rates of 18 patients were respectively 93.8%, 84.4% and 70.3%.
Conclusion:The PCDV combined with splenectomy and PGFR is safe and effective in the treatment of portal hypertensioninduced severe gastric varices with GRS, with a dissemination value for appropriate patients.

DOI:10.3760/cma.j.issn.1673-9752.2018.10.011
基金项目:福建省自然科学基金(2017J01244);福建省卫生和计划生育委员会创新课题(2014-CBX-2)
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