腹腔镜脾脏切除贲门周围血管离断术治疗Child-Pugh A/B级肝硬化门静脉高压症的临床效果分析

李昌旭; 徐露瑶; 汝娜; 任雪康; 唐朝辉; 王英超

doi:10.3969/j.issn.1001-5256.2021.03.018

腹腔镜脾脏切除贲门周围血管离断术治疗Child-Pugh A/B级肝硬化门静脉高压症的临床效果分析

DOI: 10.3969/j.issn.1001-5256.2021.03.018

吉林大学第一医院肝胆胰外二科，长春 130000

基金项目:

吉林省科技厅自然科学基金 (20200201331JC)

利益冲突声明：本研究不存在研究者、伦理委员会成员、受试者监护人以及与公开研究成果有关的利益冲突，特此声明。

作者贡献声明：李昌旭负责资料分析，撰写论文，修改论文；徐露瑶、汝娜、任雪康、唐朝辉参与收集数据；王英超负责课题设计，拟定写作思路，指导撰写文章并最后定稿。

详细信息

作者简介:
李昌旭(1993—)，男，主要从事肝胆胰脾疾病诊治方面的研究

通信作者:
王英超，yingchao11111@sohu.com

中图分类号: R575.2
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出版历程
- 收稿日期: 2020-09-06
- 录用日期: 2020-09-22
- 出版日期: 2021-03-20

Clinical effect of laparoscopic splenectomy and pericardial devascularization in portal hypertension patients with Child-Pugh A/B liver function

Second Department of Hepatopancreatobiliary Surgery, The First Hospital of Jilin University, Changchun 130000, China

摘要

摘要: 目的探讨门静脉高压症患者行腹腔镜脾脏切除贲门周围血管离断术(LSPD)的临床效果，进一步明确LSPD的远期疗效。方法选取2017年8月—2017年12月于吉林大学第一医院接受LSPD治疗的肝功能Child-Pugh A/B级门静脉高压症患者40例(外科组)；选取同期接受保守治疗的肝功能Child-Pugh A/B级门静脉高压症患者44例(内科组)。随访至2019年6月30日，记录两组患者各时间点肝功能指标、上消化道出血和门静脉血栓情况等。正态分布的计量资料两组间比较采用t检验；多组间比较采用方差分析，进一步两两比较采用Bonferroni检验。偏态分布的计量资料多组间比较采用Kruskal-Wallis H检验，进一步两两比较采用Mann-Whitney U检验检验。计数资料组间比较采用χ²检验。结果出院后6、12、24个月外科组胆碱酯酶水平明显高于内科组(t值分别为3.527、3.849、5.555，P值均＜0.05)，Child-Pugh评分相对于内科组显著降低(t值分别为2.498、2.138、2.081，P值均＜0.05)。出院后12、24个月外科组白蛋白水平高于内科组(t值分别为3.120、2.587)，上消化道出血率低于内科组(χ²值分别为4.947、5.155)，差异均有统计学意义(P值均＜0.05)。外科组出院后24个月甲胎蛋白水平显著增高人数少于内科组，差异有统计学意义(χ²=4.648，P=0.031)。出院12个月外科组门静脉血栓发生率显著高于内科组(χ²=4.395，P=0.036)。外科组患者入院时、术后12个月、术后24个月白蛋白(F=2.959，P=0.013)、胆碱酯酶(F=11.022，P＜0.001)、凝血酶原时间(H=94.100，P＜0.001)、Child-Pugh评分(F=3.742，P=0.003)均有改善。结论肝功能Child-Pugh A/B级门静脉高压症患者行LSPD能改善肝功能，降低上消化道出血率，门静脉血栓发生率较高，但可通过口服阿司匹林及利伐沙班有效降低。
- 肝硬化 /
- 高血压, 门静脉 /
- 腹腔镜脾脏切除贲门周围血管离断术
Abstract: Objective To investigate the clinical effect of laparoscopic splenectomy and pericardial devascularization (LSPD) in patients with portal hypertension and the long-term effect of LSPD. Methods A total of 40 portal hypertension patients with Child-Pugh A/B liver function who received LSPD in The First Hospital of Jilin University from August to December 2017 were enrolled as surgical group, and 44 portal hypertension patients with Child-Pugh A/B liver function who received conservative treatment during the same period of time was enrolled as internal medicine group. The patients were followed up to June 30, 2019, and liver function parameters, upper gastrointestinal bleeding, and portal vein thrombosis were recorded for all patients at each time point. The t-test was used for comparison of normally distributed continuous data between two groups; an analysis of variance was used for comparison between multiple groups, and the Bonferroni test was used for further comparison between two groups. The Kruskal-Wallis H test was used for comparison of continuous data with skewed distribution; between multiple groups, and the Mann-Whitney U test was used for further comparison between two groups. The chi-square test was used for comparison of categorical data between groups. Results At 6, 12, and 24 months after discharge, compared with the internal medicine group, the surgical group had a significantly higher level of cholinesterase (t=3.527, 3.849, and 5.555, all P < 0.05) and a significantly lower Child-Pugh score (t=2.498, 2.138, and 2.081, all P < 0.05). Compared with the internal medicine group at 12 and 24 months after discharge, the surgical group had a significantly higher level of albumin (t=3.120 and 2.587, both P < 0.05) and a significantly lower incidence rate of upper gastrointestinal bleeding (χ²=4.947 and 5.155, both P < 0.05). At 24 months after discharge, the surgical group had a significantly lower number of patients who had a significant increase in alpha-fetoprotein level than the internal medicine group (χ²=4.648, P=0.031). At 12 months after discharge, the surgical group had a significantly higher incidence rate of portal vein thrombosis than the internal medicine group (χ²=4.395, P=0.036). The surgical group had significant improvements in albumin (F=2.959, P=0.013), cholinesterase (F=11.022, P < 0.001), prothrombin time (H=94.100, P < 0.001), and Child-Pugh score (F=3.742, P=0.003) from admission to 12 and 24 months after surgery. Conclusion In portal hypertension patients with Child-Pugh A/B liver function, LSPD can improve liver function and reduce the incidence rate of upper gastrointestinal bleeding, and the high incidence rate of portal vein thrombosis can be effectively reduced by oral aspirin and rivaroxaban.
- Liver Cirrhosis /
- Hypertension, Portal /
- Laparoscopic Splenectomy And Pericardial Devascularization

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表 1 外科组和内科组患者一般资料比较

组别	例数	性别(例)		年龄(岁)	BMI(kg/m²)	血红蛋白(g/L)	高血压(例)	糖尿病(例)	胆碱酯酶(U/L)	白蛋白(g/L)	Child-Pugh评分(分)
组别	例数	男	女	年龄(岁)	BMI(kg/m²)	血红蛋白(g/L)	高血压(例)	糖尿病(例)	胆碱酯酶(U/L)	白蛋白(g/L)	Child-Pugh评分(分)
内科组	44	21	23	53.6±6.6	26.1±5.4	105.0±14.4	19	20	3901±1101	32.2±4.9	6.6±1.9
外科组	40	22	18	50.9±8.4	24.8±4.0	108.2±11.7	12	16	4088±828	30.9±5.9	6.4±1.7
统计值		χ²=0.444		t=1.590	t=1.227	t=1.102	χ²=1.564	χ²=0.255	t=0.872	t=1.114	t=0.746
P值		0.505		0.116	0.223	0.274	0.211	0.614	0.386	0.269	0.458
注：胆碱酯酶、白蛋白、Child-Pugh评分皆为入院时检测结果。

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表 2 外科组及内科组患者出院后肝功能指标及定量指标比较

组别	例数	出院后各时间点胆碱酯酶(U/L)			出院后各时间点白蛋白(g/L)			出院后各时间点Child-Pugh评分(分)
组别	例数	6个月	12个月	24个月	6个月	12个月	24个月	6个月	12个月	24个月
内科组	44	4098±710	4109±927	3949±888	31.6±5.2	30.2±5.6	30.1±6.3	6.2±1.9	6.2±2.1	6.1±2.0
外科组	40	4638±691	4844±809	5060±945	33.0±4.1	34.2±6.0	34.8±6.6	5.2±1.7	5.3±1.7	5.2±1.8
t值		3.527	3.849	5.555	1.360	3.120	2.587	2.498	2.138	2.081
P值		0.001	＜0.001	＜0.001	0.178	0.003	0.011	0.014	0.036	0.041

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表 3 外科组及内科组患者出院后上消化道出血、门静脉血栓、甲胎蛋白比较

组别	例数	出院后各时间点上消化道出血(例)		出院后各时间点门静脉血栓(例)		出院后各时间点甲胎蛋白大幅升高¹⁾(例)
组别	例数	12个月	24个月	12个月	24个月	12个月	24个月
内科组	44	16	24	4	8	12	21
外科组	40	6	12	11	14	6	10
χ²值		4.947	5.155	4.395	3.331	1.874	4.648
P值		0.026	0.023	0.036	0.068	0.171	0.031
注：1)甲胎蛋白较入院时数值增加100则为大幅升高。上消化道出血后监测生命体征及血红蛋白，根据上述指标决定保守治疗或是介入止血。

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表 4 外科组患者手术前后肝功能指标比较

时间	白蛋白(g/L)	胆碱酯酶(U/L)	凝血酶原时间(s)	Child-Pugh评分(分)
入院时	30.9±5.9	4088±828	15.3(14.4~15.9)	6.4±1.7
术后7 d	31.7±4.7	3858±894	15.3(14.6~16.0)	6.2±1.6
术后3个月	32.6±4.6	4424±1003	14.8(14.4~15.8)	5.8±1.4
术后6个月	33.0±4.1	4638±691	14.8(14.3~15.7)	5.2±1.7¹⁾
术后12个月	34.2±6.0	4844±809¹⁾	14.4(13.6~15.0)¹⁾	5.3±1.7
术后24个月	34.8±6.6¹⁾	5060±945¹⁾	14.6(13.7~15.0)¹⁾	5.2±1.8¹⁾
统计值	F=2.959	F=11.022	H=94.100	F=3.742
P值	0.013	＜0.001	＜0.001	0.003
注：与入院时比较，1)P＜0.05；术后12个月Child-Pugh评分较术后6个月轻度增加，考虑肝功能短暂波动。

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