目的 评价选择性介入治疗在原发性肝癌（HCC）门脉高压症中的应用价值。 方法 2008年11月－2011年3月，收治65例临床明确诊断的HCC伴门脉高压症患者，选择性使用肝动脉化学疗法（化疗）栓塞术、脾栓塞术、门静脉化疗栓塞术、门静脉支架、胃冠状静脉栓塞术等介入术式，术后通过观察临床指标、定期复查影像检查等了解病变转归，随访生存期并评价疗效。 结果 65例HCC患者均合并不同程度门静脉高压，其中门静脉癌栓46例中有37例显示肝动脉-门静脉分流，通过肝动脉及门静脉化疗栓塞术进行主瘤体及癌栓治疗。11例行门静脉支架置入术，支架置入后门静脉压较术前明显下降（P＜0.01），支架中位通畅时间为5.8个月。39例行胃冠状静脉和（或）胃短静脉栓塞术，术后有4例再次发生门脉高压性出血，再出血率10.26%。18例行脾动脉栓塞术，术后3个月血小板较术前显著升高（P＜0.01）。随访术后3、6、12及24个月的生存率分别为90.77%、69.23%、35.38%及13.85%。 结论 选择性联合使用各种介入术式是治疗HCC及其相关性门脉高压症的一种有效方法，可有效预防高危风险，延长患者生存期。
Objective To explore and summarize the curative effect and experience of emergency devascularization for treatment of upper gastrointestinal bleeding due to portal hypertension. Melthods The clinical data of 42 patients with upper gastrointestinal bleeding due to portal hypertension， undergoing emergency devascularization from March 2006 to July 2011 in Shengjing Hospital of China Medical University were retrospectively analyzed. Results Of the 42 cases， 29 patients underwent emergency splenectomy plus esophagogastric devascularization， 8 patients underwent emergency spleen artery ligation plus esophagogastric devascularization， and 5 patients only underwent emergency esophagogastric devascularization. The hemostasis rate at 3 hours after emergent disconnection operation was 100%. One patient died of liver failure on 8 days after operation. Three patients supervened with hemorrhage in abdominal cavity on 2 days after operation， and succeeded in hemostasis by conservative treatment. Other patients were successfullydischarged from hospital after postoperative rehabilitation for 2-4 weeks. All cases were followed up regular in 1 year after operation， 5 patients were lost to follow-up. Among the 36 cases followed up， rehaemorrhagia occurred in 1 patientin 8 months after operation， cured by endoscopic variceal ligation subsequently. A primary liver cancer occurred in 1 patient during physical examination in 7 months after operation， followed by partial hepatectomy. Other patients could complete daily life and work. Conclusions The patients suffering from upper gastrointestinal bleeding due to portal hypertension are likely to benefit from appropriate operations. Decisive emergency devascularization can stop the bleeding rapidly and effectively， and save the lives of those patients.
目的 总结经颈静脉肝内门体静脉分流术（TIPS）治疗未合并肝癌的门静脉高压症患者行脾切除术后反复上消化道出血的疗效。方法 对未合并肝癌或胆管癌的门静脉高压症合并上消化道大出血患者行脾切除术后复发出血患者行TIPS术治疗，并随访1～5年（平均3.2年）的资料进行总结与分析。结果 36例脾切除术后再出血者行TIPS术， 手术均获成功，围手术期死亡率为2.78％（1/36），死亡原因是肝性脑病。随访期间患者术后再次复发出血率为5.71％（2/35）。结论 TIPS对脾切除治疗门静脉高压症后反复出血病例的效果良好。
Objective To approach the prognosis after liver transplantation （LT） of liver function for Child grade A in patients with portal hypertension， and to compare with periesophagogastric devascularization with splenectomy （PDS）. Methods The data of 195 portal hypertension cases with Child A caused by hepatitis B cirrhosis who received surgical treatment of PDS （152 cases） or LT （43 cases） in division of liver transplantation center of West China Hospital of Sichuan University from 1999 to 2011 were retrospectively analyzed. The pre-， intra-， and postoperative variables in two groups that including patients’ age， score of Child， score of model for end-stage liver disease （MELD）， total bilirubin （TB），creatinine （Cr）， international normalized ratio （INR）， albumin （Alb）， complications of portal hypertension， amount of intraoperative bleeding and blood transfusion， operative time， and in the ICU and hospital stay time were compared. The postoperative outcomes were statistically analyzed including severe postoperative complications， short-term and long-term survival rates. Results Compared with PDS group， the amount of intraoperative bleeding and blood transfusion of LT group were morer （P＜0.05）， the operative time， in the ICU and hospital stay time of LT group were longer （P＜0.05）. The rate of severe postoperative complications in LT group was higher than that in PDS group 〔18.60% （8/43） vs. 1.97% （3/152），P＜0.05〕. The levels of TB and Cr during the postoperative period in LT group were higher than that in PDS group （P＜0.05）. Although the INR on day 1 after operation in LT group was higher than that in PDS group （P＜0.01）， but the difference disappeared soon on day 7 after operation in two groups （P＞0.05）.The 1-， 3-， and 5-year survival rates of the LT and PDS groups were 90.3%， 86.5%， 86.5%， and 100%， 100%， 100%， respectively， significant difference were observed in both short-term and long-term survival rates between the two groups （P＜0.05）. Conclusion LT offered no significant survival benefit to patients with portal hypertension and Child A due to hepatitis B cirrhosis， whereas PDS could be an effective treatment.
Objective To evaluate the therapeutic effect of selective paraesophagogastric devascularization withoutsplenectomy in treatment of portal hypertension with upper gastrointestinal hemorrhage. Methods The clinical data of 27 patients who received selective paraesophagogastric devascularization without splenectomy from 2008 to 2011 were retrospectively analyzed. The hemogram， hepatic function， perioperative compliations， and free portal pressure （FPP） were observed. The patients were followed-up and the re-bleeding rate and survival rate were observed. Results The FPP decreased significantly（P＜0.05） after operation. The complication rate was 33.3%（9/27） after operation， including2 cases（7.4%） stress ulcer bleeding， 1 case （3.7%） acute bleeding portal hypertensive gastropathy， 1 case （3.7%） deep venous thrombosis， 1 case （3.7%） acute lung injury， 1 case （3.7%） death of hepatic encephalopathy， 3 cases（11.1%） new onset portal vein thrombosis. Twenty-four patients were followed up for an average of 27 months （8-57 months）. The overal survival rate was 92.6% （25/27）. Conclusion Selective paraesophagogastric devascularization without splenectomy is an effective method for treatment of portal hypertension with upper gastrointestinal hemorrhage.
Objective To explore the feasibility and safety of liver transplantation （LT） in treatment of upper gastrointestinal hemorrhage in patients with portal hypertension， and to compare the therapeutic effects with conventional operation （CO）. Methods The clinical data of 303 patients with bleeding portal hypertension from Feb. 2009 to Feb. 2012 in the department of hepatobiliary and pancreatic surgery of First Affiliated Hospital of Zhejiang University were retrospectively analyzed. One hundred and one patients received LT procedure （LT group）， whereas the other 202 patients received CO procedure （CO group）. Postoperative follow-up period was 8-44 months （average 26 months）. Results Liver function before operation in CO group was significantly better than that in LT group（P＜0.01）. The mortality of CO group and LT group were 7.4%（14/189） and 3.0%（3/101， P=1.00）， respectively. The rebleeding rate of patients underwent LT was 2.0%（2/101）， significantly lower than that of CO group 〔9.5%（18/189）， P＜0.05〕. The vanish rate of esophagogastric varice in patients underwent LT was 86.1%（87/101）， significantly lower than that of CO group 〔54.5%（86/189）， P＜0.01〕. Conclusions LT treatment for bleeding portal hypertension is feasible and safe. Patients with good liver function despite hemorrhage history may be managed satisfactorily with conventional surgery. LT is the only curative treatment for patients with portal hypertension in end-stage liver disease.