腹腔镜脾切除联合贲门周围血管离断术治疗肝硬化门静脉高压并发食管胃底静脉曲张患者疗效研究

∗基金项目:江门市科技计划项目(编号:2019020200320002389)作者单位:529000广东省江门市南方医科大学附属江门市人民医院普外科
第一作者:李嘉兴,男,45岁,大学本科,副主任医师㊂E-mail: xiazhimeng1999@ ㊃肝硬化㊃
腹腔镜脾切除联合贲门周围血管离断术治疗肝硬化门静脉高压并发食管胃底静脉曲张患者疗效研究∗
李嘉兴,伍丽霞,尹承龙,欧阳俊光,郭永学,莫奇霏,王金重
㊀㊀ʌ摘要ɔ㊀目的㊀比较采用腹腔镜脾切除联合贲门周围血管离断术与开腹手术治疗肝硬化门静脉高压症并发食管胃底静脉曲张(EV)患者的疗效及对门脉血流动力学的影响㊂方法㊀2016年3月~2021年3月我科诊治的45例肝硬化门静脉高压症患者,其中20例接受开腹脾切除联合贲门周围血管离断术,另25例接受腹腔镜脾切除联合贲门周围血管离断术治疗㊂采用放射免疫分析法检测血浆内皮素(ET)㊁血管紧张素Ⅱ(ATⅡ)和肾素活度(PRA),使用多普勒超声诊断仪测量门静脉血流量PVF)㊁门静脉血流流速(PVV)㊁门静脉直径(PVD)和肝动脉血流量(HAF)㊂结果㊀腹腔镜组手术时间㊁术中出血量㊁术中输血量㊁术后引流管拔除时间㊁术后排气时间和拆线时间分别为(213.5ʃ20.7)min㊁(362.8ʃ56.9) ml㊁(312.5ʃ20.7)ml㊁(3.8ʃ0.6)d㊁(2.7ʃ0.4)d和(7.9ʃ1.5)d,与开腹组ʌ分别为(188.4ʃ16.9)min㊁(415.2ʃ50.7)ml㊁(349.4ʃ23.6)ml㊁(5.1ʃ0.9)d㊁(3.2ʃ0.5)d和(11.3ʃ2.1)dɔ比,差异显著(P<0.05);术后1m,腹腔镜组PVF㊁PVV㊁PVD 和HAF分别为(871.3ʃ91.5)ml/min㊁(41.5ʃ3.8)cm/s㊁(1.0ʃ0.2)cm和(872.2ʃ29.7)ml/min,与开腹组ʌ分别为(904.7ʃ
87.3)ml/min㊁(39.7ʃ3.4)cm/s㊁(1.1ʃ0.2)cm和(881.6ʃ30.5)ml/minɔ比,无显著性差异(P>0.05);术后6m,两组肝功
能指标比较,无显著性差异(P>0.05);腔镜组血浆ET㊁ATⅡ和PRA水平分别为(74.7ʃ5.1)ng/L㊁(143.3ʃ7.6)ng/L和
(71.5ʃ7.9)ng/L,与开腹组ʌ分别为(76.5ʃ6.3)ng/L㊁(146.7ʃ9.6)ng/L和(73.4ʃ7.6)ng/L,P>0.05ɔ比,无显著性差异㊂
结论㊀采取腹腔镜下脾切除联合贲门周围血管离断术治疗肝硬化门静脉高压并发EV患者可达到与开腹手术相同的疗效,对门脉血流动力学的影响与开腹手术也相差不大㊂
㊀㊀ʌ关键词ɔ㊀肝硬化;食管胃底静脉曲张;腹腔镜脾切除;贲门周围血管离断术;门脉血流动力学
㊀㊀DOI:10.3969/j.issn.1672-5069.2023.02.027
㊀㊀Laparoscopic splenectomy and pericardial devascularization in treatment of cirrhotics with esophageal varice and its impact on portal hemodynamics㊀Li Jiaxing,Wu Lixia,Yin Chenglong,et al.Department of General Surgery,Jiangmen People 's Hospital,Affiliated to Southern Medical University,Jiangmen529000,Guangdong Province,China
㊀㊀ʌAbstractɔ㊀Objective㊀The aim of this study was to compare the laparoscopic and open splenectomy and pericardial devascularization in treatment of cirrhotics with esophageal varice(EV)and its impact on portal hemodynamics.Methods㊀45 cirrhotic patients with EV were enrolled in our hospital between March2016and March2021,and20patients received open and another25patients received laparoscopic splenectomy and pericardial devascularization.Plasma endothelin(ET),angiotensin II (ATII)and plasma renin activity(PRA)were detected by radioimmunoassay.The portal vein flow(PVF),portal vein velocity (PVV),portal vein diameter(PVD)and hepatic arterial flow(HAF)were measured by Doppler ultrasonography.Results㊀The operation time,intraoperative blood loss,blood transfusion volume,removal of drainage tube,postoperative exhaust and suture removal in patients receiving laparoscopic surgery were(213.5ʃ20.7)min,(362.8ʃ56.9)ml,(312.5ʃ20.7)ml,(3.8ʃ0.6)d, (2.7ʃ0.4)d and(7.9ʃ1.5)d,significantly different as compared to[(188.4ʃ16.9)min,(415.2ʃ50.7)ml,(349.4ʃ23.6) ml,(5.1ʃ0.9)d,(3.2ʃ0.5)d and(11.3ʃ2.1)d,respectively,P<0.05]in patients receiving open operation;at the end of one month after operation,the PVF,PVV,PVD and HAF in laparoscopic surgery-treated patients were(871.3ʃ91.5)ml/min, (41.5ʃ3.8)cm/s,(1.0ʃ0.2)cm and(872.2ʃ29.7)ml/min,not significantly different compared to[(904.7ʃ87.3)ml/min, (39.7ʃ3.4)cm/s,(1.1ʃ0.2)cm and(881.6ʃ30.5)ml/min,P>0.05]in open operation-treated patients;at the end of six
months after surgery,there were no significant differences respect
to liver function tests between the two groups(P>0.05);plasma
ET,ATⅡand PRA in laparoscopic surgery-treated patients
were(74.7ʃ5.1)ng/L,(143.3ʃ7.6)ng/L and(71.5ʃ7.9)
ng/L,not significantly different compared to[(76.5ʃ6.3)ng/L,
(146.7ʃ9.6)ng/L and(73.4ʃ7.6)ng/L,respectively,P>
0.05]in open operation-treated patients.Conclusion㊀The laparoscopic splenectomy and pericardial devascularization might obtain the same efficacy of open operation in cirrhotics with EV,and the portal hemodynamics after operation is getting smooth.㊀㊀ʌKey wordsɔ㊀Liver cirrhosis;Esophageal varice;Laparoscopic splenectomy;Pericardial devascularization;Portal hemo-dynamics
㊀㊀门静脉高压症是一组由门静脉压力持续增高引起的症候群,多由肝硬化引起,是失代偿期乙型肝炎肝硬化的表现㊂当门静脉血不能顺利通过肝脏回流流入下腔静脉时,可引起门静脉压力增高,而食管胃底静脉曲张破裂出血(esophageal variceal bleeding, EVB)是导致患者死亡的主要原因之一[1]㊂目前,临床多采用药物㊁介入术和外科手术等方法治疗门静脉高压引起的EVB㊂相关研究指出,外科手术不但可预防EVB再出血,还可降低肝性脑病等并发症的发生率[2]㊂脾切除联合贲门周围血管离断术是治疗EVB患者的主要术式,可有效消除脾功能亢进症,降低门静脉压力,但患者术后可并发凝血功能障碍㊁门脉血栓形成和腹腔血管曲张等,影响术后恢复[3,4]㊂随着腹腔镜手术的发展,腹腔镜下脾切除术因具有创口小等优点,在临床上已广泛得到应用,但其治疗肝硬化门静脉高压并发EVB患者的疗效尚处于探索阶段㊂本研究比较了开腹与腹腔镜脾切除术联合贲门周围血管离断术治疗肝硬化门静脉高压并发食管胃底静脉曲张患者的疗效,并探讨了术后门脉血流动力学的变化,现报道如下㊂
1㊀资料与方法
1.1临床资料㊀2016年3月~2021年3月我院诊治的肝硬化门静脉高压症患者45例,男26例,女19例;年龄为52~69岁,平均年龄为(61.3ʃ4.5)岁㊂符合有关指南中关于肝硬化门静脉高压并发EVB 的诊断标准[5,6],其中原发性胆汁性肝硬化4例,酒精性肝炎肝硬化7例,乙型肝炎肝硬化30例,丙型肝炎肝硬化4例;Child-Pugh A级8例,B级37例㊂纳入患者存在胃镜下中㊁重度静脉曲张,伴红色征阳性㊂排除标准:(1)严重的脾周围炎及脾周围粘连;
(2)顽固性腹水;(3)合并肝癌;(4)既往有肝脏手术史;(5)食管胃底静脉曲张破裂活动性大出血㊂将患者分为两组,一组行开腹脾切除联合贲门周围血管离断术,另一组行腹腔镜脾切除联合贲门周围血管离断术,两组一般资料比较无显著性差异(P> 0.05)㊂本研究方案经我院医学伦理学委员会审核通过,患者及其家属签署知情同意书㊂
1.2治疗方法㊀在开腹手术时,行左侧肋缘下切口或左上腹旁正中切口,在切除脾脏后行贲门周围血管离断术㊂术毕,进行腹腔冲洗,放置引流管,常规逐层关腹;在腹腔镜下手术时,患者取头高20ʎ~30ʎ,采用5孔法在直视下置入腹腔镜器械㊂采用超声刀离断胃左血管及以上曲张静脉,分离胃结肠韧带,并钳夹㊁切断㊁结扎脾结肠韧带㊁脾胃韧带,离断脾蒂,将脾脏装入储物袋,用旋切器将其切碎,从操作孔中取出㊂切断胃后血管,紧邻贲门游离贲门左侧,紧邻胃壁小弯向头侧分离㊁切断胃左动脉㊁冠状静脉发向胃壁的所有分支,继续向头侧紧邻贲门和食管游离,将腹段食管游离6~8cm,离断曲张静脉,放置引流管㊂
1.3门脉血流动力学指标检测㊀使用日本ALOKA 多普勒超声诊断仪检测门静脉血流量(portal vein flow,PVF)㊁门静脉流速(portal vein velocity,PVV)㊁门静脉直径(portal vein diameter,PVD)和肝动脉血流量(hepatic arterial flow,HAF)㊂
1.4血浆指标检测㊀采用放射免疫分析法检测血浆内皮素(endothelin,ET,东亚免疫技术研究所)㊁血管紧张素Ⅱ(angiotensinⅡ,ATⅡ)和肾素活度(plasma renin activity,PRA)水平(北方生物技术研究所)㊂1.5统计学处理㊀应用IBM SPSS Statistics24.0软件进行统计学分析,对正态分布的计量资料以(xʃs)表示,采用独立t检验㊂计数资料的比较采用x2检验,P<0.05被认为差异有统计学意义㊂
2㊀结果
2.1两组手术相关指标比较㊀腹腔镜组手术时间显著长于开腹组,而术中出血量和输血量显著少于开腹组,术后引流管拔除时间㊁术后排气时间和拆线时间均显著短于开腹组(P<0.05,表1)㊂
2.2两组肝功能指标比较㊀术前和术后两组肝功能指标无显著性差异(P<0.05,表2)㊂
2.3两组门脉血流动力学指标比较㊀术前和术后1 m,两组PVF㊁PVV㊁PVF和HAF比较无显著性差异(P>0.05,表3)㊂
2.4两组血浆ET㊁ATⅡ和PRA水平比较㊀术前和术后两组血浆ET㊁ATⅡ和PRA水平比较,无显著性差异(P<0.05,表4)㊂
表1㊀两组手术相关指标(xʃs)比较
例数手术时间(min)出血量(ml)输血量(ml)引流管拔出(d)排气时间(d)拆线时间(d)腹腔镜25213.5ʃ20.7①362.8ʃ56.9①312.5ʃ20.7① 3.8ʃ0.6① 2.7ʃ0.4①7.9ʃ1.5①
开腹㊀20188.4ʃ16.9415.2ʃ50.7349.4ʃ23.6 5.1ʃ0.9 3.2ʃ0.511.3ʃ2.1㊀㊀与开腹组比,①P<0.05
表2㊀两组肝功能指标(xʃs)比较
例数TBIL(μmol/L)ALB(g/L)INR 腹腔镜组术前2518.9ʃ2.135.6ʃ1.3 1.1ʃ0.3术后6m2520.4ʃ1.936.3ʃ2.0 1.2ʃ0.4开腹组㊀术前2019.2ʃ1.735.3ʃ1.6 1.2ʃ0.5术后6m2019.8ʃ1.636.8ʃ2.1 1.1ʃ0.6
表3㊀两组门脉血流动力学指标(xʃs)变化比较
例数PVF(ml/min)PVV(cm/s)PVD(cm)HAF(ml/min)腹腔镜组术前251286.9ʃ92.316.9ʃ3.1 1.4ʃ0.2627.5ʃ27.3术后1m25871.3ʃ91.541.5ʃ3.8 1.0ʃ0.2872.2ʃ29.7开腹组㊀术前201307.2ʃ86.717.5ʃ3.9 1.5ʃ0.3629.4ʃ30.4术后1m20904.7ʃ87.339.7ʃ3.4 1.1ʃ0.2881.6ʃ30.5
表4㊀两组血浆指标(ng/L,xʃs)比较
例数ET ATⅡPRA 腹腔镜组术前25121.9ʃ9.5247.8ʃ17.8186.4ʃ9.6术后6m2574.7ʃ5.1143.3ʃ7.671.5ʃ7.9开腹组㊀术前20123.8ʃ7.9245.9ʃ16.5184.9ʃ7.5术后6m2076.5ʃ6.3146.7ʃ9.673.4ʃ7.6
2.5两组术后并发症发生情况比较㊀术后,腹腔镜组发生门静脉血栓1例,而开腹组发生胸腔积液㊁膈下脓肿和门静脉血栓各1例㊂
3㊀讨论
在脾切除联合贲门周围血管离断术后,机体血管活性物质变化会导致血管阻力的改变,降低门脉压力[7-9]㊂本研究结果显示,脾切除后两组门脉压力显著降低㊂在切除脾脏后,脾静脉汇入门静脉的血流消失,导致门脉血流量减少,进而造成门脉压力降低㊂两组门脉压力变化比较无显著性差异,表明开腹手术与腹腔镜手术对门脉压力变化的影响一致㊂从解剖学上来说,胃左动脉㊁脾动脉和肝总动脉共同发源于腹腔干动脉㊂肝动脉与门静脉分支共同汇入肝血窦[10,11]㊂术后,门脉血流量减少会导致肝血窦的压力降低,使肝动脉血流相应的增加㊂本研究结果显示,腹腔镜脾切除联合贲门周围血管离断术后,PVV降低,而HAF增加,与相关研究报道相符[12],主要是因为在行脾切除术后,腹腔干动脉压力相对恒定而血流流出道减少,导致肝动脉血流量增加㊂另一方面,门脉血流减少越多,肝血窦压力减少越明显,肝动脉血流增加越显著[13-17]㊂本研究发现,腹腔镜组术中出血量㊁术中输血量少于开腹组,术后引流管拔除时间㊁术后排气时间和拆线时间短于开腹组,表面腹腔镜脾切除术联合断流手术治疗可促进患者术后恢复,体现了腹腔镜手术的微创优点㊂
肝硬化门脉高压症患者处于高度应激状态,其肾素㊁血管紧张素-醛固酮系统被激活,肾血流量减少,刺激肾上腺皮质系统分泌醛固酮,血浆醛固酮水平升高,使得钠回收量增加,血浆胶体渗透压增加,促使下丘脑分泌抗利尿激素,加速肾小球远曲小管对水的重吸收,致使水钠潴留进一步加重[17,18]㊂代
偿期肝硬化患者血浆ET和ATⅡ显著升高[19]㊂肝硬化患者周围血管扩张,全身血管阻力降低,有效血流量减少,引起肾血流减少,肾小球旁细胞的PRA 和ATⅡ合成量增加,加重肝脏血循环紊乱和门脉高压㊂肾素-血管紧张素-醛固酮系统活性与肝血流动力学异常有关[20]㊂脾切除联合贲门周围血管离断术治疗可降低门脉压力,减轻门脉系统缺氧,引起血管内皮细胞合成ET减少[21-23]㊂
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(收稿:2022-08-08)
(本文编辑:陈宗炳)。