门静脉高压症合并脾动脉瘤的腹腔镜/开放同期手术治疗效果分析（附28例报告）

Analysis of laparoscopic/open concurrent surgical treatment for portal hypertension complicated with splenic aneurysm (28 cases)

摘要:

目的 比较门静脉高压症合并脾动脉瘤患者同期行腹腔镜/开放手术（脾动脉瘤近心端及远心端隔绝术、脾脏切除术和门-奇断流术）的临床治疗效果。方法 回顾性分析2013年1月－2020年12月28例于武汉市第一医院肝胆外科和深圳大学总医院普外科诊断为“门静脉高压症、脾功能亢进合并脾动脉瘤”的患者的临床资料，所有病例均同期腹腔镜下或者开放手术下应用“脾动脉瘤近、远心端隔绝术+脾切除术+门-奇断流术”进行治疗。患者术前均需完善腹部增强CT + CT血管造影（CTA）、彩色多普勒超声以及胃镜等检查，详细了解肝功能分级、脾脏肿大分级、脾功能亢进程度、食管胃底静脉曲张程度、脾动脉瘤在载瘤动脉上的位置、大小、外形以及与周围器官的毗邻关系等情况。术后常规复查血液分析、C反应蛋白（CRP）和肝功能。术后1～3个月门诊复查腹部增强CTA。术后门诊及电话随访7～84个月。结果 所有患者均痊愈，无腹腔积液、感染、深部脓肿、出血和胰瘘等术后并发症，围手术期及随访期间无死亡病例。腹腔镜手术组手术时间和术后住院时间较开放手术组短，术中出血量和术后3 d腹水量较开放手术组少，差异均有统计学意义（P < 0.05）。术后第3天复查血液分析、CRP和肝功能，结果显示，腹腔镜手术组白细胞（WBC）和谷草转氨酶（GOT）明显低于开放手术组，血小板（PLT）和白蛋白（ALB）明显高于开放手术组，差异均有统计学意义（P < 0.05）。术后有21例患者存在不同程度的PLT升高等脾脏功能缺失的表现，经予以口服药物（潘生丁等）治疗后，无血管相关并发症发生。结论 同期行脾动脉瘤隔绝+脾脏切除术+门-奇断流手术，能安全、有效地治疗门静脉高压症合并脾动脉瘤。腹腔镜下同期手术创伤更小，患者康复更快。相比于传统的开放手术，该手术方法可减少术中创伤，明显缩短住院时间，疗效好，值得临床推广应用。

Abstract:

Objective To compare the clinical application and therapeutic effect of laparoscopic/open surgery on patients with portal hypertension complicated with splenic aneurysm undergoing proximal and distal splenic aneurysm isolation, splenectomy and portal azygous devascularization.Methods Clinical data of 28 patients diagnosed as portal hypertension, hypersplenism complicated with splenic aneurysm from January 2013 to December 2020 were retrospectively analyzed. All the cases were treated by laparoscopic or open surgery at the same time with the surgical method of proximal and distal isolation of splenic aneurysm+splenectomy+portal azygous devascularization. Patients underwent comprehensive blood analysis, abdominal enhanced computed tomography (CT) + CT angiography (CTA), color doppler ultrasound and gastroscope preoperatively in order to evaluate the liver function, the level of splenomegaly, the degree of hypersplenism, the level of esophageal gastric varices, and the location, size, shape and adjacent to the relations with the surrounding organs of the splenic aneurysm. They also underwent postoperative routine review of blood analysis, C-reactive protein (CRP), liver function. One to three months after operation, each patient was informed to return to the clinic, and abdominal enhanced CTA was performed. Outpatient telephone follow-up lasted from 7 to 84 months.Results All the 28 patients recovered without any postoperative complications such as abdominal effusion, infection, deep abscess, hemorrhage and pancreatic fistula, and no deaths occurred during perioperative and follow-up periods. The operation time and postoperative hospital stay of the laparoscopic surgery group were shorter than those of the open surgery group, and the intraoperative blood loss and postoperative abdominal water volume at 3 d were less than those of the open surgery group, the differences were statistically significant (P < 0.05). Blood analysis, CRP and liver function were reviewed 3 days after surgery. The results showed that the white blood cell (WBC) and glutamic-oxaloacetic transaminase (GOT) in the laparoscopic surgery group were significantly lower than those in the open surgery group, while the platelet (PLT) and albumin (ALB) in the laparoscopic surgery group were significantly higher than those in the open surgery group, with statistical significance (P < 0.05). After the operation, 21 patients had different degrees of PLT and other manifestations of spleen function loss, and no vascular-related complications occurred after oral treatment with persantin.Conclusion Simultaneous splenic aneurysm isolation + splenectomy + portal azygous devascularization can safely and effectively treat portal hypertension complicated with splenic aneurysm. Laparoscopic simultaneous surgery is less invasive and patients are more likely to recover quickly. Compared with traditional open surgery, this method can reduce the intraoperative trauma and shorten the average length of hospital stay significantly, and has better clinical efficacy, which is worthy of wide clinical application.