门静脉高压症外科治疗45年回顾

中华外科杂志2000年第38卷第2期

黄r庭王维民王加其柏椿年

摘要目的：探讨门静脉高压症手术治疗的适应证、手术时机及术式的选择。方法：将45年来手术治疗的912例门静脉高压症患者，按手术时间分为三个时间组，即1978年以前，1978-1989年，1990-1998年。对每一时间段急诊与择期行分流手术、断流手术及断流术加分流术的疗效进行回顾性分析。结果：912例患者中，A、B、C各组，分流术、断流术及联合术例数分别为345例、13例、0例；84例、209例、0例；63例、204例和63例。三组急诊手术例数分别为45例、13例和4例。手术死亡率：分流术A、B、C各组分别为7.82%、7.14%和0；断流术分别为15.38%、6.28%和4.94%；联合手术C组为3.51%。脑病发生率：分流手术14.37%，断流手术5.68%，联合手术5.77%。再出血率：分流手术10.78%，断流手术18.95%，联合手术7.69%。结论：门静脉高压症手术适应证及手术时机：有出血史的患者有无手术适应证取决于肝功能，肝功能差的尽量等待好转后再行手术治疗。对于无出血史的预防性手术仍有一定的价值，预防性手术施行与否可参照食道钡餐、彩超、内镜等。急诊手术呈下降趋势。术式的选择：断流手术呈增加趋势，近年已取代分流手术成为主要术式。全门体分流手术已被小口径分流手术取代。断流手术加分流手术可有效的降低门静脉压力，又能保留一定的供肝血流。假如条件答应，是一种效果较好的手术。

关键词：高血压，门静脉门腔分流术，外科

s=“tt1“>From1953to1998，912irrhotipatientswithportalhypertensionwereoperatedon.Theexperienewithsurgialtreatmentforthesepatientsexept5ofextrahepatitypewasreviewedinthispaper.

Ofthe912patients，684weremaleand228female，agedfrom12to81yearsTheyhadesophagealvariesindifferentdegrees.664patients

Typesofoperation

Numberofoperations

>

Portosystemishuntwasperformedin431patients：portaavalshunt

From1979to1989，84patientsreeivedPSS，withanaverageof7.63patientsperyear.Amongthe84patients，

49hadPCS，14SRS，4MCS，12DSRS，3sCS，1umbilialavalshunt，and1oronoavalshunt.207patientsweresubjetedtodisonnetioninludingtransthoraiapproahin3patientswithanaverageof18.81patientsperyear.Atotalof291patientsreeivedPSSanddisonnetionwithanaverageof26.45asesperyear.

From1990to1998，2patientsunderwentPCS，and204patientsdisonnetioninludingtransetionandreanastomosisoftheloweresophagusbystaplerAverage22.66patientsunderwentsuhoperationsperyear.DisonnetionombinedwithSRSwasperformedin57patients.Atotalof63patientsreeivedoperationswithanaverageof29.22patientsperyear.

Emergenyoperation

Before1978，42patientsreeivedPSS，inludingPCSDisonnetionwasperformedin3patients.From1979to1989，3patientsweresubjetedtoPSS，a

nd10disonnetion.From1990to1998，only4patientsweresubjetedtodisonnetion.

Prophylatioperation

Before1978，112patientsreeivedPSSIntheperiodof1979to1989，31patientsdisonnetion.Duringtheperiodof1990to1998，2patientsreeivedPSS，and58disonnetion.

Operativemotality

Before1978，345patientsreeivedPSSand27died.Amongthem，eletiveoperationwasperformedin303patientsbut16died，andemergenyoperationwasperformedin42patientsbut11died.disonnetionwasperformedin13patients，but2died.Amongthem，eletiveoperationwasperformedin10patients，whereasonedied，andemergenyoperationwasperformedin3patientsandonediedafter

transthoraiapproah.

From1979to1989，84patientsreeivedPSS，but6died.Inthesepatients，eletiveoperationwasperformedin81，but5died，andemergenyoperationin3，butonedied.In207patientswhounderwentdisonnetion，13died.Amongthe207patients，eletiveoperationwasperformedin197patients，but11died，andemergenyoperationin10patients，but2died.

Duringtheperiodof1990to1998，PSSwasdonein2patientswithoutasingledeath.Disonnetionwasperformedin204patients，but10died.thisoperationinludedeletiveoperationin201patientsbut10died，andemergenyoperationin3withoutadeath.EletivedisonnetionombinedwithSRSwasperformedin57patients，but2died.

Liverfuntion

Theliverfuntionofthepatientswaslassified（Table1）.Table1LiverfuntionTotal

patientsIIIIIIPatients％Patients%Patients%Before19783589727.0918952.797220.111979-19892917224.7415753.956221.301990-19982636825.5814454.755119.39Mostpatientswerefollowedup.Thelongestdurationoffollowupwas20years，andtheshortestoneyearof398survivorswhohadundergoneshuntoperation，334（83.9

1%）werefollowedup.Of399survivorswhohadbeensubjetedtodisonnetion，343werefollowedup.

Enephalopathyourredin48patientsofthePSSgroup，19ofthedisonnetiongroup，and3ofthedisonnetionplusPSSgroup.

Rebleedingwasnotedin37patientsofthePSSgroup，65ofthedisonnetiongroup，and4ofthedisonnetionplusPSSgroup.

ThesurvivalratesareshowninTable2.

Table2.Survivalrates

Operations1year2years5years10yearsPatients％Patients％Patients％Patients％PSS298/33489.22223/27780.50148/19577.0875/11167.56Disonnetion301/34387.75231/28182.26143/17979.8877/11368.14Disonnetion+PSS47/5290.3842/4885.4123/2882.14……

DISCUSSIONindiationsandtimingforsurgialtreatmentofportalhypertension

Surgialtreatmentisintendedtopreventrebleedingfromesophagealvaries.Itsindiationsdependonpatients′liverfuntion.Forthosewithpoorliverfuntion，surgeryisonsideredafterthefuntionisimproved.generally，thepatientswithpoorliverfuntionwhounderwentsurgeryarelessthan20%inChina.Withthedevelopmentofnonoperativemethodssuhasendosopislerotherapy，TIPS，andportalhypotensivedrugs，moreandmoreirrhotipatientsavoidsurgery.Isitneessarytoperformprophylatioperationforpatientswithoutbleeding？InontrasttotheviewofWesternountries，［1］prophylatioperationwasperformedinone-fourthofourpatients，butnotlessthanone-fifth.Bleedingourredonlyin15.38%ofourpatientsafteroperation，whihislowerthan36.91%inthepatientsnotoperatedon.［2］Apartfromliverfuntion，otherindiessuhasfillingdefetsduetoesophagealvariesshownbybariummeal，enlargedoronaryveinshownbyolorultrasound，andvenousaneurysm-likehangerevealedendosopiallyarehelpfultoavoidunnessaryprophylatioperation.anation-wideinvestigationrevealedthatprophylatioperationsinChinaaountfor25%ofoperationsforportalhypertensionsinethe1970s.Emergenyoperations，however，aountfor20%ofalloperationsonernedinthe1970s，butdereasedtoabout10%inreentyears.［3］Inthisseries，emergenyoperationsametoabout1

2.56%inthe1970s，anddereasedto4.46%and1.52%inthe1980s，and1990srespetively.Inreentyears，nonoperativemethodsareinreasinglyusedforstoppingbleeding，andpatientshavemoreopportunitiestoreeiveeletiveoperations.

Rationalityandseletionofsurgialapproahes

Manyoperationsareindiatedforportalhypertension.Buttwoareommonlyused：portosystemishuntandportoazygousdisonnetion.Clinialpratiehasshownthateahoperationhasitsowntheoretialbasisandouldeffetivelystopbleeding.Thelong-termsurvivalrateisdependentuponthestabilityandimprovementofliverfuntionandthereisnodifferenebetweenthetwoofoperations.The10-yearsurvivalrateisabout70%onaverage.therefore，theinjuryorthenegativeeffetfromtheoperationistheimportantbasisforevaluatingatypeofoperation.Portosystemishunt，espeiallyportaavalshunt，interferesseverallytheportalbloodflow.ModifiedproeduressuhasrestritingshuntstomasandinterposinganartifiialvesselwithsmallaliberAmongthem，20.94%hadenephalopathyafterportaavalshunt.ThreePCSpatientsand1SRSpatienthadsevereenephalopathy.Theyalllosttheirlivingability.SRSpatientshadtoundergoreoperationtooludetheshuntforreovery.ThreePCSpatientsdiedofhepatiomasinetheoperationwasseldomperformedatthattime.Only17patientsunderwentdistalsplenorenalshuntinourdepartment.Beauseofthetehnialdiffiultyandnoimprovementinlong-termresults，thisproedurehasnotbeenappliedinreentyears.Sinethe1980s，disonnetionhasbeeninreasinglyused.Beausethebleedingfoiareremoveddiretly，hemostasisissatisfatoryandsuffiientportalinflowmaybenefittheliver.Theresultsoftheinvestigationshowedthatdisonnetionhasbeenperformedthreetimesmorethantheshuntoperationinreentyears.Mostofemergenyoperationsandprophylatioperationswereperformedbydisonnetion.［3］Inourhospital，thenumberofpatientsreeivingdisonnetionhasbeeninreasingfromtheearly1980s.Theoperationalmostreplaedshuntoperationinthe1990s.Somepatientsunderwentdirettransetionoftheloweresophaguswithstapler，butitlikelyresultedinstenosis.［4，5］Clinialfindingsshowedthatafterdisonnetionportalbloodflowmaydereasetosomeextentandrebleedingislikelytoour，beauseportalhyperdynamistateespeiallygastriongestion-ausedexaerbationofportalhypertensivegastropathy.Beginningfromthe1990s，weperformeddisonnetionombinedwithsplenorenalshuntforthepatientswithliverfuntionofgradeⅠandⅡ.Themortalityrateinthesepatientswas3.51%，lowerthantheoverallmortality.theinideneofenephalopathyandrebleedingwasalsolowerthanthatofsingleoperation，butthesurvivalrateofthepatientsdidnotinreasesignifiantly.TheresultsofombinedoperationweresimilartothosereportedinChina.［6］Inourseries，portalpressuredereaseaftersplenetomyandinreasedslightlyafterdisonnetion，butitwaslowerthanthatbeforeoperation.Splenorenalshuntloweredportalpressure，butitwashigherthanthataftersimpleshuntoperayion.Wefoundthatdisonnetionombinedwithsplenorenalshuntseemstobeabetterproedureofhoie，beauseofthedereaseoftherebleedingafteroperationduetothegrowthofnewollateralsinthestateofportalhypertension，reliefofongestionofportalhypertensivegastropathy，andflowinganastomosisbetweenthespleniandrenalveinswhihishelpfult

opreventmovementofthrombusintheresidualspleniveintotheportalvein.

Experieneswithoperativetehniques

Whethersurgialmodalityforthetreatmentofportalhypertensionisuseddependsnotonlyontheatualresults，butalsoontheviewpointsandexperieneoftheoperator.Theoperatormayperformnewoperationunfamiliartohim/her，butitisimportanttomeetthestandardofaspeialoperation.opinionssuggestedthatthehoieofdisonnetionorshuntshoulddependontheompensatorystatusofspontaneousollateralshunt，butitisdiffiulttoestimate.Inourpratie，aninisionwasmadealongtheleftsubostalmargin.theomentumveinwasatheterizedformultiplemeasurementsofportalvenouspressure.Thespleniarterywasligatedwithdoublethiksilktomakethespleenshrink.Theshrunkenspleenwaspulledoutafterdisonnetingtherelatedligments.Thehilusofthespleenwasex

amined.Ifitwassuitableforanastomosis，a4-msegmentoflongwasfreedandligatednearthehilusofthespleen，andthespleenwasresetedsubsequently.Therenalveinwasexposed，anda3-4msegmentwasisolated.Shuntwasnotperformedtransientlybeforeperiardialandloweresophagealvesselsweredisonnetedompletely.Theposteriorgastriveinandhighesophagealbranhshouldbeligatedarefully.theloweresophagusisnottranseted.Gastridisonnetionisrestritedtotheproximalhalfofthestomah.Inourseries，2patientsreeiveddisonnetiontothepylorus，andtheydiedofgastriisheminerosis.splenorenalanastomosisafterdisonnetionneeds20minutes.Thetotaloperationtimewasabout4hours.Iftheoperationdidnotprogresssmoothlyortheonditionofthepatientworsened，regulardisonnetionwouldbepreferable.Ifombinedoperationmaytakealongtimeorproduemassivebleeding，itwouldnotbevaluable.

>单位：黄r庭北京医科大学第一医院外科，北京100034，中国

王维民北京医科大学第一医院外科，北京100034，中国

王加其北京医科大学第一医院外科，北京100034，中国

柏椿年北京医科大学第一医院外科，北京100034，中国

［1］ShwarzSI.Portalhypertension.In：ShwarzSI，ed.priniplesofsurgery.7thed.NewYork：Mgraw-Hill，1999.1415-1435.

［2］BaiCN，ChangBH，HuangYT.Re-evaluationofprophylatiportosystemishunt.ChinJSurg，1986，24：719-721.