(精品)协和外科课件2 (2).ppt

门脉高压的外科治疗门脉高压的外科治疗中国协和医科大学 北京协和医院外科 唐伟松Table 1.Aetiological factors in extrahepatic portal venous hypertension in adults.Intra-abdominal infectionsIntra-abdominal infections HypercoagulableHypercoagulable states statesAppendicitisAppendicitisMyeloproliferativeMyeloproliferative syndrome syndromeOther forms of peritonitisOther forms of peritonitisPregnancyPregnancyInflammatory bowel diseaseInflammatory bowel diseaseOral contraceptive drugsOral contraceptive drugsBiliaryBiliary tract infection tract infectionCollagen diseasesCollagen diseasesPancreatitisPancreatitisThrombophlebitisThrombophlebitis migransmigransPostoperative factorsPostoperative factors Retroperitoneal fibrosis Retroperitoneal fibrosisSplenectomySplenectomy Increased portal venous flowIncreased portal venous flowPortosystemicPortosystemic shunts shunts Hepatic Hepatic arteriovenousarteriovenous fistulae fistulaeBiliaryBiliary surgery surgery TraumaTrauma UnknownUnknownTumourTumour invasion and compression invasion and compressionHepatocellularHepatocellular carcinoma carcinomaOther malignant Other malignant tumourstumoursTable1.Number of cases of bleeding ectopic varices reported in the literature.Sites of Sites of EctopicEctopic VaricesVaricesNumber of Reported CasesNumber of Reported CasesDuodenumDuodenum2828Jejunum and IleumJejunum and Ileum2929ColonColon2424RectumRectum1414IleostomyIleostomy or Colostomy or Colostomy4444PeritoneumPeritoneum1616Common Bile Duct and GallbladderCommon Bile Duct and Gallbladder 3 3VaginaVagina 2 2BladderBladder 1 1门脉高压症外科治疗的解剖基础门脉高压症外科治疗的解剖基础门脉高压的侧枝门脉高压的侧枝 冠状V.1.门V.胃底食道V.奇V.胃短V.2.直肠上V.直肠下V.腹壁上V.上腔V.3.脐旁V.腹壁下V.下腔V.4.肠系膜上、下、V.下腔V.（Retzius静脉丛）正常门静脉系统的局解剖正常门静脉系统的局解剖胃食道静脉曲张出血的外科治疗胃食道静脉曲张出血的外科治疗门体静脉吻合（分流）术门体静脉吻合（分流）术门体静脉吻合（分流）术门体静脉吻合（分流）术1.1.门、腔门、腔V.V.吻合吻合2.2.脾肾静脉吻合脾肾静脉吻合 远端脾肾远端脾肾V.V.吻合术（吻合术（WarrensWarrens术）术）近端近端脾肾脾肾V.V.吻合术吻合术3.3.肠系膜肠系膜V.V.、下腔下腔V.V.吻合吻合 （侧例吻合、（侧例吻合、H H形吻合）形吻合）下腔下腔V.-V.-肠系膜上肠系膜上V.V.端侧吻合端侧吻合4.4.冠状冠状V.V.、上腔上腔V.V.吻合吻合5.5.经颈内静脉穿刺、肝内门、体经颈内静脉穿刺、肝内门、体V.V.分流术（分流术（TIPSTIPS）Risk of future bleeding according to variceal size.W.G.RECTOR Jr AND T.B.REYNOLDSRisk of future bleeding according to Risk of future bleeding according to varicealvariceal size.size.Size of Size of varicesvarices Small or none Medium Large Small or none Medium Large 13/51 9/41 11/23 0-49 13/51 9/41 11/23 0-49 2/34 7/39 13/38 0-6 2/34 7/39 13/38 0-6 0/34 4/24 9/17 1-86 0/34 4/24 9/17 1-86 0/16 0/24 12/60 12 0/16 0/24 12/60 12 15/135 30/128 45/138 15/135 30/128 45/138 (11%)(23%)(33%)(11%)(23%)(33%)Follow upFollow up(months)(months)门奇静脉断流术门奇静脉断流术n n贲门周围血管离断术n n食管下端横断术n n胃底模断术n n食管下端胃底切除术n n冠状V.栓塞术Liver Function(Childs)ClassificationBilirubin3mg3albumin3.5mg13-3.5mg23.0mg3ascitesnone1 easily controlled2difficult controlled3hepatoencephalopathynone1moderate2severe3nutritional stategood1moderate2poor3A5-8B9-11C12-15肝功能分级标准（1983年分级标准）I II IIII II IIISGPTSGPT 正常正常 2 2 2倍正常值倍正常值白蛋白白蛋白 3.5 3.5g 2.5-3.5g 2.5gg 2.5-3.5g 2.5g胆红素胆红素 1.2 2.0mgmg 1.2-2.0mg 2.0mg腹水腹水 -少量、易控少量、易控 大量大量脑病脑病 -I III II沉血酶元时间沉血酶元时间 正常正常 延长延长3-63-6秒秒 延长延长6 6秒以上秒以上血管栓塞术n n冠状静脉栓塞n n胃短静脉栓塞n n脾动脉栓塞n n曲张静脉栓塞脾肿大、脾亢的外科治疗脾肿大、脾亢的外科治疗n n脾切除n n脾A部分栓塞顽固性腹水的治疗顽固性腹水的治疗n n腹腔、上下腔V.转流术n nLeeven氏管n nDever氏管门脉高压症手术并发症门脉高压症手术并发症n n创面出血n n胃肠道出血n n腹水n n腹腔感染n n肠系膜静脉血栓形成n n肝功能衰竭n n肝性脑病各种治疗的生存率各种治疗的生存率 1 1year 2years 5years 10years year 2years 5years 10years PSS 89.2 80.5 77.0 67.5Disconection 88.7 82.2 79.8 68.1S+D 90.3 85.4 82.14 Chines J surg 2000;38(2):85选择手术方式的有关因素选择手术方式的有关因素1.肝功能 分级 Childs 分级 中华医学会 分级2.脾功能亢进的程度3.医生的经验 各种手术的死亡率手术方式手术方式手术死亡率手术死亡率 作者作者 年代年代门门-腔分流（急症）腔分流（急症）42%42%OrloffOrloff 1984 1984SugiuraSugiura 术术 12%12%SugiuraSugiura 1973 1973食管下段横断食管下段横断 18%18%CuirentCuirent HepatologyHepatology 吻合吻合 吻合吻合 急症急症33%33%择期择期12%12%SugiuraSugiura 术术 3 3.5-9.7%5-9.7%Sugiura 1988 Sugiura 1988Warrens Warrens 术术dsrs 4dsrs 4.4%.4%脾脾-肾分流肾分流 1.5%1.5%吴光汉等吴光汉等19881988脾脾-肾分流肾分流 8.7%8.7%协和协和 1986 1986 主要手术种类n n分流术n n近端脾近端脾-肾静脉吻合肾静脉吻合n n远端脾远端脾-肾静脉吻合肾静脉吻合n n门腔静脉吻合门腔静脉吻合n n肠腔静脉吻合肠腔静脉吻合n n冠状静脉冠状静脉-下腔静脉吻合下腔静脉吻合n n门奇静脉阻断术n n食道下段贲门周围血管食道下段贲门周围血管离断术离断术n n冠状静脉结扎术冠状静脉结扎术n n胃底静脉缝扎术胃底静脉缝扎术n n食道下段贲门切除术食道下段贲门切除术食道静脉曲张的手术选择食道静脉曲张的手术选择肝功能手术方式 1分流术 2分流术或断流术 3断流术门脉高压的治疗门脉高压的治疗n 肝移植