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学科主题肿瘤学
脾切除断流后门静脉系统血栓形成介入治疗的短期及长期临床疗效分析
唐小龙
2016-05-13
导师刘福全
专业肿瘤学
授予单位北京大学
授予地点北京大学第九临床医学院
学位硕士
关键词脾切除 门静脉血栓 介入治疗 门脉高压症 肝硬化 肝癌
其他题名Short-time and long-term efficacy of interventional treatment in portal vein thrombosis after splenectomy
分类号R735.7
摘要

背景和目的:在我国慢性肝炎病人与肝炎病毒携带者接近一亿人,其中相当一部分发展成肝硬化,而不少肝硬化病人又可进一步发展为肝癌患者,临床上约80%的肝癌合并肝硬化患者伴有不同程度的门静脉高压症状,严重的门脉高压症不仅导致针对肝癌治疗的难度和风险加大,而且其所引起的食管胃底静脉曲张破裂出血也严重威胁着患者的生命,脾功能亢进、顽固性腹水等严重影响着患者的生活质量。在肝癌的治疗中,处理肝癌合并或继发门脉高压症是临床重点之一。目前在我国脾切除加贲门周围血管离断术是治疗门静脉高压症上消化道出血的主流术式,其止血效果可靠,对肝功能要求低,特别适合在我国占绝大多数的肝硬化和肝癌伴门静脉高压上消化道出血的患者,而脾切除术后易导致门静脉系统内血栓形成,根据发病缓急、解剖部位、栓塞程度及临床症状等不同,有内科抗凝溶栓治疗、外科手术、介入治疗等不同治疗方法。介入治疗已成为治疗门静脉血栓的重要方法之一,已取得临床肯定疗效,但仍缺乏大样本的病例研究,技术分析及长期临床疗效随访结果等。本研究旨在通过大样本的病例分析来研究脾切除术后门静脉系统血栓形成介入治疗的短期及长期临床疗效。

方法:回顾分析自2001年6月至2012年6月就诊于北京世纪坛医院介入科的319例经脾切除断流术后门静脉系统血栓形成并进行介入治疗的患者临床资料,所有患者均纳入研究。分析不同血栓类型的患者进行相应类型介入手术的短期及长期疗效。

结果:手术成功315例,成功率98.7%(315/319),失败的4例介入手术均为经颈静脉肝内门体分流术(Transjugular Intrahepatic Portosystemic Shunt,TIPS)术。门静脉系统血流完全改善百分率为67.6%(213/315)、门静脉系统血流好转百分率为26.7%(84/315)、门静脉系统血流完全没有改善百分率为5.7%(18/315)。门静脉压力由术前(3.97±0.74 kPa)降至术后(2.68±0.52 kPa;P<0.01)。随访情况:手术成功的315例患者均术后随访,随访时间为术后24个月至96个月(平均随访时间长度为44.8个月)。术后临床症状:消化道出血术后复发(或术后新出现的出血)113例(35.9%),复发或新出现的顽固性腹水或胸水19 例(6.0%),术后肝性脑病发生79例(25.1%),其中76例(33.2%)为TIPS后发生。术后再次介入治疗情况:315例患者,再次行介入治疗1次158 例(47.3%),2次115例(36.5%),3次以上42例(13.3%);其中经皮肝穿刺门静脉局部溶栓18例、经肠系膜上动脉间接溶栓4例、TIPS分流通道球囊成形术14例,支架成形术121例。术后总的血栓复发32例,复发率10.2%(32/315)。TIPS累积再狭窄率:1年、2年、3年、4年、5年分别为:15.2%(35/230)、21.3%(49/230)、32.7%(66/202)、40.8%(71/174)、54.9%( 73/133)。生存率:1年、2年、3年、4年、5年分别为:98.7%(311/315)、88.3(278/315)、83.1%(245/295)、78.5%(194/247)、74.5%( 137/184)。

结论:对于脾切除断流后门静脉系统血栓形成的患者,介入治疗是一种安全有效的治疗手段,根据血栓的发生时间、程度、部位、是否伴有侧枝形成及临床症状需采取不同的介入治疗方法,这对提高手术成功率和临床疗效十分重要。

英文摘要

Background and Objective: Nearly one hundred million people suffered from Chronic hepatitis or carried hepatitis B virus in our country. And considerable part of them developed into liver cirrhosis and a lot of liver cirrhosis patients further develop into liver cancer . About 80% of patients who had hepatic carcinoma and liver cirrhosis accompanied by varying degrees clinical symptoms of portal hypertension,Severe portal hypertension is not only enhance the difficulty and risk of the treatment to liver cancer ,and also caused ruptured bleeding of esophageal gastric varices which poses a serious threaten to the life of patients,the splenic hyperfunction and refractory ascites seriously affecting the patient's quality of life.In the treatment of liver cancer, dealing with liver cancer merger or secondary of portal hypertension is still one of clinical focus. Interiorly,splenectomy with periesophagogastric devascularization is the main treatment method of upper gastrointestinal bleeding in portal hypertension now ,it had reliable hemostatic effect and low requirements for liver function,it is particularly suitable for most of the patients in our country with portal hypertension upper digestive tract hemorrhage complicated with Cirrhosis and cancer of the liver .Portal venous system thrombosis after splenectomy is a common disease,According to the differences of priorities  morbidity and anatomical site,the severity of portal vein thrombosis and clinical symptoms,there are different treatments such as internal medicine anticoagulation and thrombolytic therapy,surgery, interventional treatment etc,and the interventional therapy has become one of the important methods of the treatments of portal vein thrombosis after Splenectomy and the feasibility of the technique has been confirmed by clinical results.However, there was no large cohort studies about technical analysis and follow-up results of long-term clinical. This study aimed to investigate short-time and long-term efficacy of interventional treatment in portal vein thrombosis after Splenectomy.

Method: A retrospective analysis was made on clinical data of 319 cases who received  interventional treatment with portal vein thrombosis after Splenectomy from June 2001 to June 2012 in our center. All cases were included in the study. Different surgical approaches were applied in patients with different types of thrombosis, and their short-time and long-term efficacies were analyzed.

Results: The surgical success rate of interventional treatment implemented in  portal vein thrombosis after Splenectomy is 98.7% (315/319), all the four cases of failure had TIPS. Portal system bloodstream totally inproved account for 67.6% (212/315), somehow improved 26.7% (84/315), not improved 5.7% (18/315). Mean portal pressure dropped from (3.97±0.74 kPa) preoperatively to (2.68±0.52 kPa) postoperatively (P<0.01). Follow-up:All the operation successful 315 patients were followed-up for 24 to 96 months(mean 44.8months) . Postoperative clinical symptoms: 113 patients  (35.9%) occurred recurrent or emerging gastrointestinal bleeding, and 19 patients (6.0%) occurred recurrent or emerging refractory ascites or hydrothorax. 79 patients occurred hepatic encephalopathy (25.1%), 76 cases of them occurred after TIPS. Postoperative re-intervention treatment: among the 315 patients, there were 158 (47.3%) receiving single intervention, 115 (36.5%) twice and 42 (13.3%) over 3 times; 18 underwent percutaneous puncture local thrombolysis for portal vein thrombosis, 4 underwent indirect thrombolysis through superior mesenteric artery, 14 TIPS shunt balloon angioplasty and 121 stent-assisted angioplasty. Total of recurrent thrombosis is 32 cases, recurrence rate was 10.2% (32/315).TIPS cumulative restenosis rate was 15.2% (35/230),21.3% (49/230),32.7% (66/202),40.8% (71/174),54.9% ( 73/133)  in the first 1, 2, 3, 4 and 5 years following surgery. The 1, 2, 3, 4, 5-year survival rate was 98.7%, 88.3%, 83.1%, 78.5%, 74.5% respectively.

Conclusion: Interventional treatment implemented in portal vein thrombosis after Splenectomy is a safe and effective treatment. It can adopt different intervention methods according to the occurrence time, severity, position of thrombogenesis, clinical symptoms and whether the collateral formation.It would be very important to improve the success rate of surgery and clinical curative effect.

语种中文
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文献类型学位论文
条目标识符http://ir.bjmu.edu.cn/handle/400002259/124805
专题北京大学第九临床医学院
作者单位北京大学第九临床医学院
推荐引用方式
GB/T 7714
唐小龙. 脾切除断流后门静脉系统血栓形成介入治疗的短期及长期临床疗效分析[D]. 北京大学第九临床医学院. 北京大学,2016.
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