肝硬化门静脉高压症不同手术方式与血栓形成

摘要

目的：分析肝硬化门静脉高压症患者不同手术方式与血栓形成部位及发生率的关系,探讨血栓形成的机制。方法回顾性分析2011年1月至2012年12月间收治的资料完整的72例肝硬化门静脉高压症患者术前术后的临床资料,脾切除+断流手术25例,选择性断流术15例,脾切除脾肾静脉分流+断流的联合手术32例,分析术前术后患者的血小板数量、凝血功能、门静脉血流动力学状况与血栓形成的关系。结果①术前在有无门静脉系统血栓形成的两组间各项凝血功能参数差异均无统计学意义,唯门静脉血流速度在血栓组较无血栓组显著减慢(P <0.05)。②术后有无血栓形成的两组间血小板数量无明显差异,D-二聚体均较正常值为高,但两组间差异无统计学意义。③行断流术的25例患者,在术后2周和2个月时,血栓形成率可达100%,主要为脾静脉血栓,其中12例(48%)合并门静脉主干及分支血栓。④选择性断流术后以脾静脉血栓为主,部分可向门静脉主干或分支蔓延,将胃冠状静脉-食管旁静脉闭塞；部分患者仅显示肠系膜上静脉-胃冠状静脉-食管旁静脉,门静脉主干、分支及脾静脉均闭塞。⑤脾肾静脉分流加断流的联合手术后2个月时血栓形成率最高(75%),至6个月时下降至41%,为3组中最低(P <0.01)。主要为门静脉主干和(或)分支血栓,除1例外,肠系膜上静脉-脾静脉-吻合口血流通畅。结论肝硬化门静脉高压症患者的术前、术后门静脉系统血栓形成与凝血功能改变无明显关系。无论何种手术,术后门静脉系统均有血栓形成可能,术式不同其血栓发生的部位可不同,血栓形成主要与门静脉系统血流动力学改变有关。联合手术后,虽门静脉主干及分支内可有血栓形成,但吻合口通畅,基本上无术后再出血,且肝性脑病发生率低、易被处理,应成为首选。%Objective To analyze the relationship between different operation patterns for patients with portal hypertension caused by hepatic cirrhosis and examine the incidence,position and risk fac-tors of portal vein thrombosis (PVT).Methods From January 201 1 to December 2012,72 patients with portal hypertension in liver cirrhosis were analyzed.There were devascularization (n =25 ),se-lective devascularization (n = 1 5 )and splenorenal shunt associated with devascularization (n = 32). Platelet,prothrombin time,hemodynamics of portal vein and the incidence of PVT were analyzed be-fore and after operation.Results Pre-operative blood velocity of portal vein decreased remarkably in patients with PVT while both groups showed no difference in factors of coagulation function.No re-markable inter-group difference existed in platelet levels,but D-dimer levels were higher than nor-mal though the inter-group difference was insignificant.At 2 weeks and 2 months post-devascular-ization,splenic vein thrombosis extended to trunk and branch(es)of portal vein in 12(48%)patients. After selective devascularization,some of them had thrombosis extended to trunk of portal vein or branch(es)and blocked gastric coronary vein and paraesophageal vein.While another few patients on-ly showed superior mesenteric vein,gastric coronary vein and paraesophageal vein,with splenic vein and portal vein completely blocked.After splenorenal shunt associated with devascularization,the rate of PVT was 75% at 2 months post-operation and decreased to 41 % at 6 months.And it was the lowest among 3 groups.Most patients suffered partial thrombosis in portal trunk and(or)branches while only 1 case had the partially blocked shunt.Conclusion Occurring at different sites in trunk or branch(es)of portal vein after splenorenal shunt associated with devascularization,PVT may be cor-related with the changes of portal hemodynamics.