门静脉高压症外科治疗45年回顾
黄莚庭 王维民 王加其 柏椿年
摘要 目的:探讨门静脉高压症手术治疗的适应证、手术时机及术式的选择。 方法:将45年来手术治疗的912例门静脉高压症患者，按手术时间分为三个时间组，即1978年以前(A组)，1978-1989年(B组)，1990-1998年(C组)。对每一时间段急诊与择期行分流手术、断流手术及断流术加分流术(联合术)的疗效进行回顾性分析。 结果:(1)912例患者中，A、B、C各组，分流术、断流术及联合术例数分别为345例、13例、0例；84例、209例、0例；63例、204例和63例。三组急诊手术例数分别为45例、13例和4例。(2)手术死亡率：分流术A、B、C各组分别为7.82%、7.14%和0；断流术分别为15.38%、6.28%和4.94%；联合手术C组为3.51%。(3)脑病发生率：分流手术14.37%，断流手术5.68%，联合手术5.77%。(4)再出血率：分流手术10.78%，断流手术18.95%，联合手术7.69%。 结论:(1)门静脉高压症手术适应证及手术时机：有出血史的患者有无手术适应证取决于肝功能，肝功能差的尽量等待好转后再行手术治疗。对于无出血史的预防性手术仍有一定的价值，预防性手术施行与否可参照食道钡餐、彩超、内镜等。急诊手术呈下降趋势。(2)术式的选择：断流手术呈增加趋势，近年已取代分流手术成为主要术式。全门体分流手术已被小口径分流手术取代。断流手术加分流手术可有效的降低门静脉压力，又能保留一定的供肝血流。如果条件允许，是一种效果较好的手术。
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关键词:高血压，门静脉 门腔分流术，外科
From 1953 to 1998, 912 cirrhotic patients with portal hypertension were operated on. The experience with surgical treatment for these patients except 5 of extrahepatic type was reviewed in this paper.
METHODS
Patients
Of the 912 patients, 684 were male and 228 female, aged from 12 to 81 years (average 43.9 years). They had esophageal varices in different degrees. 664 patients (72.80%) had a history of bleeding from the upper digestive tract, including postoperative rebleeding in 35 patients, of whom 19 were subjected to portosystemic shunt, 11 portoazygous disconnection, and 5 both operations.
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Child-Pugh classification of liver function showed grade Ⅰ in 155 patients (16.99%), grade Ⅱ in 593 (65.09%), and grade Ⅲ in 164 (17.99%).
Types of operation
Number of operations
Portosystemic shunt was performed in 431 patients: portacaval shunt (PCS) in 148, splenorenal shunt (SRS) 236, mesocaval shunt (MCS) 27, distal splenorenal shunt (DSRS) 14，and others 6. Portoazygous disconnection was carried out in 424 patients, including 5 patients receiving transthoracic operation. Shunt combined with disconnection was given to 57 patients.
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Different periods of operations
Before 1978, portosystemic shunt (PSS) was performed in 345 patients (14.37 patients per year on average), including PCS in 97, SRS 222, MCS 23, DSRS 2, and splenocaval shunt (SCS) 1. Thirteen patients were subjected to disconnection, including transthoracic operation in 2. From 1953 to 1978, a total of 358 patients received PSS and disconnection (mean 14.92 patients).
From 1979 to 1989, 84 patients received PSS, with an average of 7.63 patients per year. Among the 84 patients, 49 had PCS, 14 SRS, 4 MCS, 12 DSRS, 3 SCS, 1 umbilical caval shunt, and 1 coronocaval shunt. 207 patients were subjected to disconnection including transthoracic approach in 3 patients with an average of 18.81 patients per year. A total of 291 patients received PSS and disconnection with an average of 26.45 cases per year.
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From 1990 to 1998, 2 patients underwent PCS, and 204 patients disconnection including transection and reanastomosis of the lower esophagus by stapler (18 patients). Average 22.66 patients underwent such operations per year. Disconnection combined with SRS was performed in 57 patients. A total of 63 patients received operations with an average of 29.22 patients per year.
Emergency operation
Before 1978, 42 patients received PSS, including PCS (21 patients), SRS (16), and MCS (5). Disconnection was performed in 3 patients. From 1979 to 1989, 3 patients were subjected to PSS, and 10 disconnection. From 1990 to 1998, only 4 patients were subjected to disconnection.
, 百拇医药
Prophylactic operation
Before 1978, 112 patients received PSS (32.46% of 345 patients), and 3 disconnection (23.07% of 13). In the period of 1979 to 1989, 31 patients (36.90%) received PSS and 42 (20.28% ) disconnection. During the period of 1990 to 1998, 2 patients received PSS, and 58 (28.43%) disconnection.
Operative motality
Before 1978, 345 patients received PSS and 27 (7.82%) died. Among them, elective operation was performed in 303 patients but 16 (5.28%) died, and emergency operation was performed in 42 patients but 11 (26.19%) died. Disconnection was performed in 13 patients, but 2 (15.38%) died. Among them, elective operation was performed in 10 patients, whereas one (10.0%) died, and emergency operation was performed in 3 patients (33.3%) and one died after transthoracic approach.
, 百拇医药
From 1979 to 1989, 84 patients received PSS, but 6 (7.14%) died. In these patients, elective operation was performed in 81, but 5 (6.17%) died, and emergency operation in 3, but one (33.33%) died. In 207 patients who underwent disconnection, 13 (6.28%) died. Among the 207 patients, elective operation was performed in 197 patients, but 11 (5.58%) died, and emergency operation in 10 patients, but 2 (20.0%) died.
During the period of 1990 to 1998, PSS was done in 2 patients without a single death. Disconnection was performed in 204 patients, but 10 (4.97%) died. This operation included elective operation in 201 patients but 10 (4.97%) died, and emergency operation in 3 without a death. Elective disconnection combined with SRS was performed in 57 patients, but 2 (3.51%) died.
, 百拇医药
Liver function
The liver function of the patients was classified (Table 1).
Table 1 Liver function
Total
patients
I
II
III
Patients
%
Patients
, 百拇医药
%
Patients
%
Before 1978
358
97
27.09
189
52.79
72
20.11
1979-1989
291
, 百拇医药
72
24.74
157
53.95
62
21.30
1990-1998
263
68
25.58
144
54.75
51
, 百拇医药
19.39
RESULTS
Most patients were followed up. The longest duration of follow up was 20 years, and the shortest one year (mean 8 years and 10 months). Of 398 survivors who had undergone shunt operation, 334 (83.91%) were followed up. Of 399 survivors who had been subjected to disconnection, 343 (85.96%) were followed up.
Encephalopathy occurred in 48 patients (14.37%) of the PSS group, 19 (5.68%) of the disconnection group, and 3 (5.77%) of the disconnection plus PSS group.
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Rebleeding was noted in 37 patients (10.78%) of the PSS group, 65 (18.95%) of the disconnection group, and 4 (7.69%) of the disconnection plus PSS group.
The survival rates are shown in Table 2.
Table 2. Survival rates
Operations
1 year
2 years
5 years
10 years
, 百拇医药
Patients
%
Patients
%
Patients
%
Patients
%
PSS
298/334
89.22
223/277
80.50
, http://www.100md.com
148/195
77.08
75/111
67.56
Disconnection
301/343
87.75
231/281
82.26
143/179
79.88
77/113
, http://www.100md.com
68.14
Disconnection+PSS
47/52
90.38
42/48
85.41
23/28
82.14……
DISCUSSIONIndications and timing for surgical treatment of portal hypertension
Surgical treatment is intended to prevent rebleeding from esophageal varices. Its indications depend on patients′ liver function. For those with poor liver function, surgery is considered after the function is improved. Generally, the patients with poor liver function who underwent surgery are less than 20% in China. With the development of nonoperative methods such as endoscopic sclerotherapy, TIPS, and portal hypotensive drugs, more and more cirrhotic patients avoid surgery. Is it necessary to perform prophylactic operation for patients without bleeding? In contrast to the view of Western countries,[1] prophylactic operation was performed in one-fourth of our patients, but not less than one-fifth. Bleeding occurred only in 15.38% of our patients after operation, which is lower than 36.91% in the patients not operated on.[2] Apart from liver function, other indices such as filling defects due to esophageal varices shown by barium meal, enlarged coronary vein shown by color ultrasound,and venous aneurysm-like change revealed endoscopically are helpful to avoid unnecssary prophylactic operation. A nation-wide investigation revealed that prophylactic operations in China account for 25% of operations for portal hypertension since the 1970s. Emergency operations, however, account for 20% of all operations concerned in the 1970s, but decreased to about 10% in recent years.[3] In this series, emergency operations came to about 12.56% in the 1970s, and decreased to 4.46% and 1.52% in the 1980s, and 1990s respectively. In recent years, nonoperative methods are increasingly used for stopping bleeding, and patients have more opportunities to receive elective operations.
, 百拇医药
Rationality and selection of surgical approaches
Many operations are indicated for portal hypertension. But two are commonly used: portosystemic shunt and portoazygous disconnection. Clinical practice has shown that each operation has its own theoretical basis and could effectively stop bleeding. The long-term survival rate is dependent upon the stability and improvement of liver function and there is no difference between the two of operations. The 10-year survival rate is about 70% on average. Therefore, the injury or the negative effect from the operation is the important basis for evaluating a type of operation. Portosystemic shunt, especially portacaval shunt, interferes severally the portal blood flow. Modified procedures such as restricting shunt stomas and interposing an artificial vessel with small caliber (Sarfeh′s procedure) rarely interfere the portal flow. End-to-side portacaval shunt, however, has still been adopted worldwide.[4] In our series, the patients who had undergone portosystemic shunt had encephalopathy after operation (14.37%). Among them, 20.94% (33/148) had encephalopathy after portacaval shunt. Three PCS patients and 1 SRS patient had severe encephalopathy. They all lost their living ability. SRS patients had to undergo reoperation to occlude the shunt for recovery. Three PCS patients died of hepatic coma since the operation was seldom performed at that time. Only 17 patients underwent distal splenorenal shunt in our department. Because of the technical difficulty and no improvement in long-term results, this procedure has not been applied in recent years. Since the 1980s, disconnection has been increasingly used. Because the bleeding foci are removed directly, hemostasis is satisfactory and sufficient portal inflow may benefit the liver. The results of the investigation showed that disconnection has been performed three times more than the shunt operation in recent years. Most of emergency operations and prophylactic operations were performed by disconnection.[3] In our hospital, the number of patients receiving disconnection has been increasing from the early 1980s. The operation almost replaced shunt operation in the 1990s. Some patients underwent direct transection of the lower esophagus with stapler, but it likely resulted in stenosis.[4，5] Clinical findings showed that after disconnection portal blood flow may decrease to some extent and rebleeding is likely to occur, because portal hyperdynamic state especially gastric congestion-caused exacerbation of portal hypertensive gastropathy. Beginning from the 1990s, we performed disconnection combined with splenorenal shunt for the patients with liver function of gradeⅠand Ⅱ. The mortality rate in these patients was 3.51%, lower than the overall mortality. The incidence of encephalopathy and rebleeding was also lower than that of single operation, but the survival rate of the patients did not increase significantly. The results of combined operation were similar to those reported in China.[6] In our series, portal pressure decrease after splenectomy and increased slightly after disconnection, but it was lower than that before operation. Splenorenal shunt lowered portal pressure, but it was higher than that after simple shunt operayion. We found that disconnection combined with splenorenal shunt seems to be a better procedure of choice, because of the decrease of the rebleeding after operation due to the growth of new collaterals in the state of portal hypertension, relief of congestion of portal hypertensive gastropathy, and flowing anastomosis between the splenic and renal veins which is helpful to prevent movement of thrombus in the residual splenic vein to the portal vein.
, 百拇医药
Experiences with operative techniques
Whether surgical modality for the treatment of portal hypertension is used depends not only on the actual results, but also on the viewpoints and experience of the operator. The operator may perform new operation unfamiliar to him/her, but it is important to meet the standard of a special operation. Opinions suggested that the choice of disconnection or shunt should depend on the compensatory status of spontaneous collateral shunt, but it is difficult to estimate. In our practice, an incision was made along the left subcostal margin. The omentum vein was catheterized for multiple measurements of portal venous pressure. The splenic artery was ligated with double thick silk to make the spleen shrink. The shrunken spleen was pulled out after disconnecting the related ligments. The hilus of the spleen was examined. If it was suitable for anastomosis, a 4-cm segment of long was freed and ligated near the hilus of the spleen, and the spleen was resected subsequently. The renal vein was exposed, and a 3-4cm segment was isolated. Shunt was not performed transiently before pericardial and lower esophageal vessels were disconnected completely. The posterior gastric vein and high esophageal branch should be ligated carefully. The lower esophagus is not transected. Gastric disconnection is restricted to the proximal half of the stomach. In our series, 2 patients received disconnection to the pylorus, and they died of gastric ischemic necrosis. Splenorenal anastomosis after disconnection needs 20 minutes. The total operation time was about 4 hours. If the operation did not progress smoothly or the condition of the patient worsened, regular disconnection would be preferable. If combined operation may take a long time or produce massive bleeding, it would not be valuable.
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作者单位：黄莚庭 北京医科大学第一医院外科，北京 100034，中国
王维民 北京医科大学第一医院外科，北京 100034，中国
王加其 北京医科大学第一医院外科，北京 100034，中国
柏椿年 北京医科大学第一医院外科，北京 100034，中国
REFERENCES
[1] Schwarz SI. Portal hypertension. In: Schwarz SI,ed. Principles of surgery. 7th ed. New York: Mcgraw-Hill, 1999. 1415-1435.
[2] Bai CN, Chang BH, Huang YT. Re-evaluation of prophylactic portosystemic shunt. Chin J Surg, 1986, 24: 719-721.
, 百拇医药
[3] Huang YT, Wang WM, Dai ZB. Investigation of portal hypertension in China. Chin J Surg，1998， 36: 324-326.
[4] Eckhauser FE, Raper SE, Tureotte JG. Cirrhosis and portal hypertension. In: Greenfield LG ed. Surgery, scientific principle and practice. 2nd ed. Philadelphia: Lippincott-Raven, 1997: 972-1008.
[5] Wang WM, Wang JQ, Huang YT. Evaluation of esophagus stapler in disconnection. Chin J General Surg，1997， 12: 353-355.
[6] Gao DM, He ZS, Wang JS, et al. The long-term effect of splenorenal shunt combined with disconnection on portal hypertension. Chin J Surg，1998，36:327-329., 百拇医药
摘要 目的:探讨门静脉高压症手术治疗的适应证、手术时机及术式的选择。 方法:将45年来手术治疗的912例门静脉高压症患者，按手术时间分为三个时间组，即1978年以前(A组)，1978-1989年(B组)，1990-1998年(C组)。对每一时间段急诊与择期行分流手术、断流手术及断流术加分流术(联合术)的疗效进行回顾性分析。 结果:(1)912例患者中，A、B、C各组，分流术、断流术及联合术例数分别为345例、13例、0例；84例、209例、0例；63例、204例和63例。三组急诊手术例数分别为45例、13例和4例。(2)手术死亡率：分流术A、B、C各组分别为7.82%、7.14%和0；断流术分别为15.38%、6.28%和4.94%；联合手术C组为3.51%。(3)脑病发生率：分流手术14.37%，断流手术5.68%，联合手术5.77%。(4)再出血率：分流手术10.78%，断流手术18.95%，联合手术7.69%。 结论:(1)门静脉高压症手术适应证及手术时机：有出血史的患者有无手术适应证取决于肝功能，肝功能差的尽量等待好转后再行手术治疗。对于无出血史的预防性手术仍有一定的价值，预防性手术施行与否可参照食道钡餐、彩超、内镜等。急诊手术呈下降趋势。(2)术式的选择：断流手术呈增加趋势，近年已取代分流手术成为主要术式。全门体分流手术已被小口径分流手术取代。断流手术加分流手术可有效的降低门静脉压力，又能保留一定的供肝血流。如果条件允许，是一种效果较好的手术。
, http://www.100md.com
关键词:高血压，门静脉 门腔分流术，外科
From 1953 to 1998, 912 cirrhotic patients with portal hypertension were operated on. The experience with surgical treatment for these patients except 5 of extrahepatic type was reviewed in this paper.
METHODS
Patients
Of the 912 patients, 684 were male and 228 female, aged from 12 to 81 years (average 43.9 years). They had esophageal varices in different degrees. 664 patients (72.80%) had a history of bleeding from the upper digestive tract, including postoperative rebleeding in 35 patients, of whom 19 were subjected to portosystemic shunt, 11 portoazygous disconnection, and 5 both operations.
, http://www.100md.com
Child-Pugh classification of liver function showed grade Ⅰ in 155 patients (16.99%), grade Ⅱ in 593 (65.09%), and grade Ⅲ in 164 (17.99%).
Types of operation
Number of operations
Portosystemic shunt was performed in 431 patients: portacaval shunt (PCS) in 148, splenorenal shunt (SRS) 236, mesocaval shunt (MCS) 27, distal splenorenal shunt (DSRS) 14，and others 6. Portoazygous disconnection was carried out in 424 patients, including 5 patients receiving transthoracic operation. Shunt combined with disconnection was given to 57 patients.
, http://www.100md.com
Different periods of operations
Before 1978, portosystemic shunt (PSS) was performed in 345 patients (14.37 patients per year on average), including PCS in 97, SRS 222, MCS 23, DSRS 2, and splenocaval shunt (SCS) 1. Thirteen patients were subjected to disconnection, including transthoracic operation in 2. From 1953 to 1978, a total of 358 patients received PSS and disconnection (mean 14.92 patients).
From 1979 to 1989, 84 patients received PSS, with an average of 7.63 patients per year. Among the 84 patients, 49 had PCS, 14 SRS, 4 MCS, 12 DSRS, 3 SCS, 1 umbilical caval shunt, and 1 coronocaval shunt. 207 patients were subjected to disconnection including transthoracic approach in 3 patients with an average of 18.81 patients per year. A total of 291 patients received PSS and disconnection with an average of 26.45 cases per year.
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From 1990 to 1998, 2 patients underwent PCS, and 204 patients disconnection including transection and reanastomosis of the lower esophagus by stapler (18 patients). Average 22.66 patients underwent such operations per year. Disconnection combined with SRS was performed in 57 patients. A total of 63 patients received operations with an average of 29.22 patients per year.
Emergency operation
Before 1978, 42 patients received PSS, including PCS (21 patients), SRS (16), and MCS (5). Disconnection was performed in 3 patients. From 1979 to 1989, 3 patients were subjected to PSS, and 10 disconnection. From 1990 to 1998, only 4 patients were subjected to disconnection.
, 百拇医药
Prophylactic operation
Before 1978, 112 patients received PSS (32.46% of 345 patients), and 3 disconnection (23.07% of 13). In the period of 1979 to 1989, 31 patients (36.90%) received PSS and 42 (20.28% ) disconnection. During the period of 1990 to 1998, 2 patients received PSS, and 58 (28.43%) disconnection.
Operative motality
Before 1978, 345 patients received PSS and 27 (7.82%) died. Among them, elective operation was performed in 303 patients but 16 (5.28%) died, and emergency operation was performed in 42 patients but 11 (26.19%) died. Disconnection was performed in 13 patients, but 2 (15.38%) died. Among them, elective operation was performed in 10 patients, whereas one (10.0%) died, and emergency operation was performed in 3 patients (33.3%) and one died after transthoracic approach.
, 百拇医药
From 1979 to 1989, 84 patients received PSS, but 6 (7.14%) died. In these patients, elective operation was performed in 81, but 5 (6.17%) died, and emergency operation in 3, but one (33.33%) died. In 207 patients who underwent disconnection, 13 (6.28%) died. Among the 207 patients, elective operation was performed in 197 patients, but 11 (5.58%) died, and emergency operation in 10 patients, but 2 (20.0%) died.
During the period of 1990 to 1998, PSS was done in 2 patients without a single death. Disconnection was performed in 204 patients, but 10 (4.97%) died. This operation included elective operation in 201 patients but 10 (4.97%) died, and emergency operation in 3 without a death. Elective disconnection combined with SRS was performed in 57 patients, but 2 (3.51%) died.
, 百拇医药
Liver function
The liver function of the patients was classified (Table 1).
Table 1 Liver function
Total
patients
I
II
III
Patients
%
Patients
, 百拇医药
%
Patients
%
Before 1978
358
97
27.09
189
52.79
72
20.11
1979-1989
291
, 百拇医药
72
24.74
157
53.95
62
21.30
1990-1998
263
68
25.58
144
54.75
51
, 百拇医药
19.39
RESULTS
Most patients were followed up. The longest duration of follow up was 20 years, and the shortest one year (mean 8 years and 10 months). Of 398 survivors who had undergone shunt operation, 334 (83.91%) were followed up. Of 399 survivors who had been subjected to disconnection, 343 (85.96%) were followed up.
Encephalopathy occurred in 48 patients (14.37%) of the PSS group, 19 (5.68%) of the disconnection group, and 3 (5.77%) of the disconnection plus PSS group.
, http://www.100md.com
Rebleeding was noted in 37 patients (10.78%) of the PSS group, 65 (18.95%) of the disconnection group, and 4 (7.69%) of the disconnection plus PSS group.
The survival rates are shown in Table 2.
Table 2. Survival rates
Operations
1 year
2 years
5 years
10 years
, 百拇医药
Patients
%
Patients
%
Patients
%
Patients
%
PSS
298/334
89.22
223/277
80.50
, http://www.100md.com
148/195
77.08
75/111
67.56
Disconnection
301/343
87.75
231/281
82.26
143/179
79.88
77/113
, http://www.100md.com
68.14
Disconnection+PSS
47/52
90.38
42/48
85.41
23/28
82.14……
DISCUSSIONIndications and timing for surgical treatment of portal hypertension
Surgical treatment is intended to prevent rebleeding from esophageal varices. Its indications depend on patients′ liver function. For those with poor liver function, surgery is considered after the function is improved. Generally, the patients with poor liver function who underwent surgery are less than 20% in China. With the development of nonoperative methods such as endoscopic sclerotherapy, TIPS, and portal hypotensive drugs, more and more cirrhotic patients avoid surgery. Is it necessary to perform prophylactic operation for patients without bleeding? In contrast to the view of Western countries,[1] prophylactic operation was performed in one-fourth of our patients, but not less than one-fifth. Bleeding occurred only in 15.38% of our patients after operation, which is lower than 36.91% in the patients not operated on.[2] Apart from liver function, other indices such as filling defects due to esophageal varices shown by barium meal, enlarged coronary vein shown by color ultrasound,and venous aneurysm-like change revealed endoscopically are helpful to avoid unnecssary prophylactic operation. A nation-wide investigation revealed that prophylactic operations in China account for 25% of operations for portal hypertension since the 1970s. Emergency operations, however, account for 20% of all operations concerned in the 1970s, but decreased to about 10% in recent years.[3] In this series, emergency operations came to about 12.56% in the 1970s, and decreased to 4.46% and 1.52% in the 1980s, and 1990s respectively. In recent years, nonoperative methods are increasingly used for stopping bleeding, and patients have more opportunities to receive elective operations.
, 百拇医药
Rationality and selection of surgical approaches
Many operations are indicated for portal hypertension. But two are commonly used: portosystemic shunt and portoazygous disconnection. Clinical practice has shown that each operation has its own theoretical basis and could effectively stop bleeding. The long-term survival rate is dependent upon the stability and improvement of liver function and there is no difference between the two of operations. The 10-year survival rate is about 70% on average. Therefore, the injury or the negative effect from the operation is the important basis for evaluating a type of operation. Portosystemic shunt, especially portacaval shunt, interferes severally the portal blood flow. Modified procedures such as restricting shunt stomas and interposing an artificial vessel with small caliber (Sarfeh′s procedure) rarely interfere the portal flow. End-to-side portacaval shunt, however, has still been adopted worldwide.[4] In our series, the patients who had undergone portosystemic shunt had encephalopathy after operation (14.37%). Among them, 20.94% (33/148) had encephalopathy after portacaval shunt. Three PCS patients and 1 SRS patient had severe encephalopathy. They all lost their living ability. SRS patients had to undergo reoperation to occlude the shunt for recovery. Three PCS patients died of hepatic coma since the operation was seldom performed at that time. Only 17 patients underwent distal splenorenal shunt in our department. Because of the technical difficulty and no improvement in long-term results, this procedure has not been applied in recent years. Since the 1980s, disconnection has been increasingly used. Because the bleeding foci are removed directly, hemostasis is satisfactory and sufficient portal inflow may benefit the liver. The results of the investigation showed that disconnection has been performed three times more than the shunt operation in recent years. Most of emergency operations and prophylactic operations were performed by disconnection.[3] In our hospital, the number of patients receiving disconnection has been increasing from the early 1980s. The operation almost replaced shunt operation in the 1990s. Some patients underwent direct transection of the lower esophagus with stapler, but it likely resulted in stenosis.[4，5] Clinical findings showed that after disconnection portal blood flow may decrease to some extent and rebleeding is likely to occur, because portal hyperdynamic state especially gastric congestion-caused exacerbation of portal hypertensive gastropathy. Beginning from the 1990s, we performed disconnection combined with splenorenal shunt for the patients with liver function of gradeⅠand Ⅱ. The mortality rate in these patients was 3.51%, lower than the overall mortality. The incidence of encephalopathy and rebleeding was also lower than that of single operation, but the survival rate of the patients did not increase significantly. The results of combined operation were similar to those reported in China.[6] In our series, portal pressure decrease after splenectomy and increased slightly after disconnection, but it was lower than that before operation. Splenorenal shunt lowered portal pressure, but it was higher than that after simple shunt operayion. We found that disconnection combined with splenorenal shunt seems to be a better procedure of choice, because of the decrease of the rebleeding after operation due to the growth of new collaterals in the state of portal hypertension, relief of congestion of portal hypertensive gastropathy, and flowing anastomosis between the splenic and renal veins which is helpful to prevent movement of thrombus in the residual splenic vein to the portal vein.
, 百拇医药
Experiences with operative techniques
Whether surgical modality for the treatment of portal hypertension is used depends not only on the actual results, but also on the viewpoints and experience of the operator. The operator may perform new operation unfamiliar to him/her, but it is important to meet the standard of a special operation. Opinions suggested that the choice of disconnection or shunt should depend on the compensatory status of spontaneous collateral shunt, but it is difficult to estimate. In our practice, an incision was made along the left subcostal margin. The omentum vein was catheterized for multiple measurements of portal venous pressure. The splenic artery was ligated with double thick silk to make the spleen shrink. The shrunken spleen was pulled out after disconnecting the related ligments. The hilus of the spleen was examined. If it was suitable for anastomosis, a 4-cm segment of long was freed and ligated near the hilus of the spleen, and the spleen was resected subsequently. The renal vein was exposed, and a 3-4cm segment was isolated. Shunt was not performed transiently before pericardial and lower esophageal vessels were disconnected completely. The posterior gastric vein and high esophageal branch should be ligated carefully. The lower esophagus is not transected. Gastric disconnection is restricted to the proximal half of the stomach. In our series, 2 patients received disconnection to the pylorus, and they died of gastric ischemic necrosis. Splenorenal anastomosis after disconnection needs 20 minutes. The total operation time was about 4 hours. If the operation did not progress smoothly or the condition of the patient worsened, regular disconnection would be preferable. If combined operation may take a long time or produce massive bleeding, it would not be valuable.
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作者单位：黄莚庭 北京医科大学第一医院外科，北京 100034，中国
王维民 北京医科大学第一医院外科，北京 100034，中国
王加其 北京医科大学第一医院外科，北京 100034，中国
柏椿年 北京医科大学第一医院外科，北京 100034，中国
REFERENCES
[1] Schwarz SI. Portal hypertension. In: Schwarz SI,ed. Principles of surgery. 7th ed. New York: Mcgraw-Hill, 1999. 1415-1435.
[2] Bai CN, Chang BH, Huang YT. Re-evaluation of prophylactic portosystemic shunt. Chin J Surg, 1986, 24: 719-721.
, 百拇医药
[3] Huang YT, Wang WM, Dai ZB. Investigation of portal hypertension in China. Chin J Surg，1998， 36: 324-326.
[4] Eckhauser FE, Raper SE, Tureotte JG. Cirrhosis and portal hypertension. In: Greenfield LG ed. Surgery, scientific principle and practice. 2nd ed. Philadelphia: Lippincott-Raven, 1997: 972-1008.
[5] Wang WM, Wang JQ, Huang YT. Evaluation of esophagus stapler in disconnection. Chin J General Surg，1997， 12: 353-355.
[6] Gao DM, He ZS, Wang JS, et al. The long-term effect of splenorenal shunt combined with disconnection on portal hypertension. Chin J Surg，1998，36:327-329., 百拇医药