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Individualized Treatment on Patients with Budd-Chiari Syndrome

目的 探讨布-加综合征的个体化治疗。 方法 我们对首都医科大学附属复兴医院及宣武医院、二炮总医院及其他医院2004年2月至2009年5月期间会诊收治的20例布-加综合征患者的临床资料进行回顾性分析。结果 20例患者中术后24 h死亡1例（5.0%），死于DIC； 19例顺利出院。19例患者术后均获随访，随访时间（34.7±3.3）个月，其中恢复良好者占73.7%（14/19）； 1例（5.3%）行肠-腔-颈转流术者，术后间断出现肝性脑病，短期住院治疗后可以改善； 术后18个月1例（5.3%）行肠-腔转流术者因全身脏器衰竭死亡。结论 个体化手术治疗方案可明显提高布-加综合征患者的生存率。

Surgical Management of Suprarenal Aortic Occlusion with Takayasu’s Arteritis

目的 探讨大动脉炎所致肾动脉上腹主动脉闭塞的手术治疗方法。方法 回顾性分析1例肾动脉上腹主动脉闭塞行腹主动脉-双股动脉人工血管搭桥手术治疗的患者的临床资料,并进行文献复习。结果 术后患者头痛明显好转，血压由术前的220/110 mm Hg(1 mm Hg=0.133 kPa)降至160/100 mm Hg,双下肢踝肱指数由0.50升至1.19。术后2周复查CTA示人工血管通畅，术后3个月复查彩超示人工血管通畅，血压在(140～150)/(80～95) mm Hg间波动，双眼视力1.0左右，已恢复正常生活。结论 大动脉炎所致肾动脉上腹主动脉闭塞常会影响多个重要脏器的供血，病变复杂，手术时机及方法的正确选择及长期抗炎治疗可以提高患者的治疗效果。

儿童巨大颈内动脉瘤切除并直接重建的手术治疗（附1例报道）

Treatment of Stubborn Ascites with Precondition of Circulation of Mesoatrial Shunt

目的 探讨布加综合征肠房转流术后顽固性腹水的治疗。方法 对2008年收治的1例经多次治疗(包括肠房转流术)后均于短期内复发的布加综合征患者进行回顾性分析。结果 临床表现为重度腹水致呼吸困难，CT静脉造影检查示肠房人工血管通畅但血流量低，考虑吻合口狭窄所致。术中探查发现吻合口极度狭窄，用带外支撑环的补片重建吻合口，疗效满意。结论 复杂或经多次手术或介入治疗的布加综合征患者，要遵循个体化治疗原则，强调术前明确诊断及选择正确治疗方案和手术方式。

布加综合征介入治疗后支架金属支断裂取出1例报道

1例股静脉至无名静脉金属异物的外科治疗

　　患者，男，39岁。3年前因大面积烧伤在外院治疗，2年后经X线拍片见一金属导丝从右股静脉直到无名静脉（图1）,遂切开右股静脉欲取出导丝，但见部分导丝已与静脉内膜黏合，无法取出，手术失败; 后再次经对侧股静脉入径，用抓捕器从无名静脉将导丝套住并向下行套至第二腰椎水平处即无法下行，考虑腰二椎体以下导丝已与下腔静脉黏合,再将抓捕器进入右股静脉也无法抓捕导丝，手术再次失败（图2）。后收治于第二炮兵总医院，决定采用导管套切分离摘取法，经术前准备后于全麻下行第3次手术。手术沿右股部原切口进入，瘢痕密集，分离困难。逐步显露出右股总及股深浅静脉并分别过带控制，沿右股总静脉触及硬条索样物，向下延及股浅静脉。切开右股总静脉，见导丝与股静脉后壁完全贴合，被光滑内膜覆盖（图3）。切开后壁内膜显露导丝，小心地将其自股浅静脉抽出，检查导丝完整，试牵引并不会被拉伸或折断（图4）。用6 F椎动脉造影管沿导丝插入，导丝由导管壁上的预开孔处引出并固定，此后小心地沿金属异物推进导管，至进入约5 cm处即无法前进； 换用10 F SteerEase输送导管以同法推进（图5），此过程中不断转动并前后移动导管，前进十分困难，操作达40 min后导管进入约30 cm至超过腰二水平，小心将导丝和导管向下同时牵引，将异物完整取出（图6）。患者术后恢复顺利，满意出院。拟服抗凝药3～6个月。　　讨论　　静脉内金属异物多是外伤或医源性所致，临床罕见，治疗困难。本例长条金属异物位于无名静脉和股静脉之间。以往手术和介入治疗未能成功的原因在于导丝在体内时间过长，已与血管融合一体。本例于第二炮兵总医院成功治疗的关键在于将导丝从血管融合体中游离出来。避免盲目暴力拉扯,否则会出现导致患者生命危险的大出血。宜选择直型且韧性好的导管，便于导管旋转进入且不会损伤周围静脉管壁。术中证实导丝无明显腐蚀表现，所以沿导丝同轴缓慢向上推进导管穿破下腔静脉的可能性不大。我们将导丝游离端穿入套管后从预先自制的侧壁孔引出，在固定导丝的前提下采用推进管鞘的方法　（图5）完成手术（应用杠杆原理）， 这是我们在手术室而不是在导管室施行治疗的根本原因，如有条件在透视下缓慢插入导管会更安全。但是必须指出的是，如果在股部切口发现导丝游离端已经被腐蚀且很易折断时，我们则会中止该治疗方案，因为笔者曾手术取出留置体内的自无名静脉到肝内留存11年的塑料套管，极易折断，最终是分为数段后全部取出。若本例导丝随着置入时间的延长，亦达到此程度，显然不宜采用上述方法。本例手术成功的关键在于术前充分准备、可行的方案及术中精细的操作。在取出异物后，可能的大范围静脉内膜损伤，因而防止术后附壁血栓形成和肺栓塞至为重要，因而需予抗凝治疗。

Diagnosis and Treatment of Prehepatic Portal Hypertension

Objective To explore the clinical presentation and diagnosis and treatment of prehepatic portal hypertension （PPH） and discuss its surgical strategies. Methods Forty-six cases of PPH treated in the 2nd Artillery General Hospital and Peking Union Medical College Hospital from January 2000 to May 2009 were analyzed retrospectively, including 2 cases of Abernethy abnormality. All patients were evaluated by indirect portal vein angiography, CT angiography and (or) portal duplex system Doppler ultrasonography before treament. Surgical strategies included: 23 cases with meso-caval shunt, 8 cases with splenectomy and spleno-renal vein shunt, 1 case with porta-caval shunt, 2 cases with paraumbilical vein-jugular vein shunt, 3 cases with portal azygous disconnection, 1 cases with splenectomy and portal azygous disconnection, 1 case with sigmoidostomy and closed the fistula of sigmoid six months later, 1 case with resection of part of small intestine due to acute extensive thrombosis of portal vein system, 4 cases with selective superior mesenteric artery and (or) splenic artery thrombolytic infusion therapy, 2 cases remained no-surgical option and underwent conservative treatment. Results Forty-four patients were followed-up from 2 months to 5 years， average of 23.4 months, one patient without surgical treatment was lost. Satisfactory outcomes were obtained in 34 patients with various shunts, which expressed as a release of hypersplenism and gastrointestinal hemorrhage. Two cases were treated with meso-caval shunt because of rehemorrhage in month 13 and 24 and one died in month 8 after disconnection, one died on day 40 after thrombolytic therapy due to putrescence of intestines, one who remained no-surgical option underwent hemorrhage 4 months later, and then went well by conservative treatment. Conclusion The key of treatment of PPH is to reduce the pressure of hepatic portal vein. Surgical managements of shunt and selective superior mesenteric artery and (or) splenic artery thrombolytic infusion therapy are safe and effective, but individual treatment strategy should be performed.

Application of Paraumbilical Vein in Surgical Shunt of Portal Hypertension

目的 探讨附脐静脉在门静脉高压分流术中的应用。方法 对第二炮兵总医院2009年收治的2例经多次治疗后复发的布加综合征患者利用明显扩张的附脐静脉进行门体分流术。结果 术后门静脉压力均明显降低， 2患者分别在术后随访7和5个月，疗效满意。结论 对于复杂重症的门静脉高压患者，明显扩张并压力增高的附脐静脉可用于门腔静脉转流，术式简单有效。

Effect of Venous Retransfusion of Ascites on Treatment of Complicated Patients with Budd-Chiari Syndrome

Objective To explore the methods and effect of venous retransfusion of ascites on the treatment of the complicated patients with Budd-Chiari syndrome.Methods Eighteen complicated and (or) recrudescent patients with Budd-Chiari syndrome were treated by venous retransfusion of ascites between March 2006 and July 2009. The changes in abdominal girth, body weight, the urine volume of 24 h, liver function, renal function, and serum electrolyte measurements before and after treatment were compared. Results After retransfusion of 5 000 ml to 7 800 ml (mean 6 940 ml) ascites, the abdominal girth of patients decreased (Plt;0.05), the urine volume of 24 h tended to normal and during which no serious side-effect happened. The levels of serum BUN, CREA, prothrombin time (PT), and activated partial thromboplastin time (APTT) decreased significantly (Plt;0.05), furthermore the levels of total albumen and albumin increased significantly (Plt;0.05). The changes of serum electrolyte measurements were not significant (Pgt;0.05). The follow-up period for all the patients was in the range of 4 to 37 months (mean 19 months). Then 12 patients were treated by the second operation at 3-6 months after discharge. Conclusions The ascites retransfusion provides a safe and effective treatment option for patients with refractory ascites, and yields a higher likelihood of discharge compared with conventional paracentesis. It is useful in improving quality of life and winning the operational chance for such as patients with complicated Budd-Chiari syndrome.

Surgical Treatment of Carotid Body Tumor while Absence of Opposite Carotid

目的 探讨对侧颈动脉已被切除的颈动脉体瘤的手术方法。方法 左颈动脉体瘤患者1例，女，54岁。右侧颈动脉31年前因右颈动脉体瘤手术已经切除，本次手术以成对的蚊式钳逐步直接分离至瘤体与颈内动脉的Gordon-Tayler白线，在保证颈内动脉完整的情况下，完整切除瘤体及包裹其内的颈外动脉。结果 患者术后无声音嘶哑、呛咳、头晕等并发症，顺利出院。结论 充分的术前准备及正确的分离平面是保证手术顺利的关键。