肝硬化门脉高压症治疗后再出血分流手术治疗

肝硬化门静脉高压症患者食管静脉曲张套扎术后

复发再出血治疗方法的选择

卢焕元 黄飞舟 聂晚频 刘浔阳

【摘要】 目的 比较内镜治疗、中心性脾静脉-肾静脉分流术或脾静脉-腔静脉分流术和门静脉-奇静脉断流术3种不同方法治疗肝硬化门脉高压症患者食管静脉曲张套扎术后复发再出血的临床疗效。 方法 2005年3月至2011年3月中南大学湘雅三医院普外科收治的肝硬化门脉高压症食管静脉曲张套扎术后复发再出血190例患者，随机分为内镜治疗组（72例）、中心性脾静脉-肾静脉或脾静脉-腔静脉分流术组（56例）和门静脉-奇静脉断流术组（62例）3组。内镜治疗组患者继续采用以内镜套扎术为主的综合治疗。分流术组患者采用加中心性脾静脉-肾静脉分流术（切除脾，将脾静脉近端与左肾静脉端侧吻合）或脾静脉-腔静脉分流术，血管吻合口直径大小限定为10 mm。断流术组患者采用脾切除加门静脉-奇静脉断流术。观察术后3组患者的近期疗效和并发症，并进行术后定期复查、随访。随访统计指标包括：复发出血、静脉曲张复发、肝性脑病、门静脉高压性胃病、死亡的例数以及分析死因。分别比较分流术组与内镜治疗组、分流术组与断流术组的各项随访指标，统计采用 检验。结果 3组患者经治疗后均成功止血，内镜治疗组有1例（1%）患者套扎后6 d大出血，经三腔二囊管压迫及药物治疗后缓解。断流术组和分流术组治疗后的门静脉压力均较治疗前明显降低（41±6 vs 25±4mmHg；38±5 vs 16±4 mmHg ，t=17.47,25.71，均为P<0.05）；与断流术组比较，分流术组治疗后的门静脉压力更低（25±4 vs 16±4 mmHg ，t=12.20，P<0.05）。断流术组围手术期门静脉血栓形成率明显高于分流术组（Χ²=4.62， P<0.05）。分流术组的复发出血率、食管静脉曲张复发率、门脉高压性胃病发生率、肝性脑病发生率均低于内镜治疗组和断流术组，且总住院时间和总住院费用亦低于内镜治疗组和断流术组（分流术组与内镜治疗组的总住院时间、费用比较，t=116.79，19.58，均为P<0.05；分流术组与断流术组的总住院时间、费用比较，t=31.96，12.84，均为P<0.05）。 结论 对肝硬化食管静脉曲张内镜套扎术后复发再出血患者，中心性脾静脉-肾静脉分流术或脾静脉-腔静脉分流术的临床效果优于门静脉-奇静脉断流术和内镜治疗。

Treatment selection for hepatocirrhosis portal hypertension patients with recurrent hemorrhage after endoscopic variceal ligation LU Huan-yuan, HUANG Fei-zhou, NIE Wan-pin, LIU Xun-yang. Department of General Surgery, The Third Xiangya Hospital of Central South University，Changsha 410007,China

Corresponding author: LIU Xun-yang, Email: xy3wk@yahoo.com.cn

【Abstract】 Objective To compare the effects of endoscopic variceal ligation(EVL),central splenorenal or splenocaval shunt and port-azygos devascularization in treating the recurrent hemorrhage after EVL for hepatocirrhosis portal hypertension with esophageal varice. Methods Clinical data were collected from 190 patients with recurrence of bleeding after EVL for hepatocirrhosis portal hypertension with esophageal varice from March 2005 to March 2011. All patients were randomly assigned to three treatment groups: endoscopic treatment group (n=72),splenorenal/splenocaval shunt group(n=56) and devascularization group (n=62).Patients in the endoscopic treatment group continued to received EVL treatment. In the shunt group, the patients underwent spleen resection plus splenorenal/splenocaval shunt, in which anastomosis of near-end of splenic vein to end-to-side of left renal or splenocaval shunt wasperformed with the diameter of stoma less than 10 mm. Spleen resection plus port-azygos devascularization were applied in the devascularization group. Perioperative assessment and postoperative follow-up examinations were performed in all patients. Results All patients in the three groups stopped bleeding after treatment. One patient in the endoscopic treatment group developed massive hemorrhage after 6 days later after EVL and the hemorrhage was relieved after inserting sengstaken-blakemore tube and medicine treatment. The portal pressure in the splenorenal/splenocaval shunt group and devascularization group were reduced obviously (41±6 vs 25±4mmHg;38±5 vs 16±4 mmHg ,t=17.47,25.71,P<0.05); The portal pressure in the splenorenal/splenocaval shunt group was lower than that in devascularization group(25±4 vs 16±4 mmHg ,t=12.20,P<0.05). The incidence of perioperative portal vein thrombosis was higher in deavascularization group compared with splenorenal/splenocaval shunt group(Χ²=4.032，P<0.05).The rates of rebleeding, recurrance of esophageal varice, portal hypertensive gastropathy (PHG) and hepatic encephalopathy in splenorenal/splenocaval shunt group were lower compared with the endoscopic treatment and devascularization group. The total hospitalization time and costs in splenorenal /splenocaval shunt group were also less than those in endoscopic treatment and devascularization groups(P<0.05). Conclusion Compared with endoscopic treatment and port-azygos devascularization, splenorenal or splenocaval shunt demonstrated better effect in treating hepatocirrhosis portal hypertension with esophageal varice rebleeding after endoscopic variceal ligation.