协和外科课件2

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1、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Table1.Aetiologicalfactorsinextrahepaticportalvenoushypertensioninadults.Intra-abdominalinfectionsHypercoagulablestatesAppendicitisMyeloproliferativesyndromeOtherformsofperitonitisPregnancyInflammatoryboweldiseaseOralcontraceptivedrugsBiliarytractinfectionCollage

2、ndiseasesPancreatitisThrombophlebitismigransPostoperativefactorsRetroperitonealfibrosisSplenectomyIncreasedportalvenousflowPortosystemicshuntsHepaticarteriovenousfistulaeBiliarysurgeryTraumaUnknownTumourinvasionandcompressionHepatocellularcarcinomaOthermalignanttumoursTable1.Numberofcasesof

3、bleedingectopicvaricesreportedintheliterature.SitesofEctopicVaricesNumberofReportedCasesDuodenum28JejunumandIleum29Colon24Rectum14IleostomyorColostomy44Peritoneum16CommonBileDuctandGallbladder3Vagina2Bladder1门脉高压症外科治疗的解剖基础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

4、膜上、下、V.下腔V.（Retzius静脉丛）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门体静脉吻合（分流）术1.门、腔V.吻合2.脾肾静脉吻合远端脾肾V.吻合术（Warrens术）近端脾肾V.吻合术3.肠系膜V.、下腔V.吻合（侧例吻合、H形吻合）下腔V.-肠系膜上V.端侧吻合4.冠状V.、上腔V.吻合5.经颈内静脉穿刺、肝内门、体V.分流术（TIPS）Riskoffuturebleedingaccordingtovaricealsize.W.G.RECTORJrANDT.B.REYNOLDSRiskoffuturebleedingaccordingtovarice

5、alsize.SizeofvaricesSmallornoneMediumLarge13/519/4111/230-492/347/3913/380-60/344/249/171-860/160/2412/601215/13530/12845/138(11%)(23%)(33%)Followup(months)门奇静脉断流术贲门周围血管离断术食管下端横断术胃底模断术食管下端胃底切除术冠状V.栓塞术LiverFunction(Child’s)ClassificationBilirubin<2mg12-3mg2>3mg3albumin>3.5mg13-3.5mg2<3.0mg3a

6、scitesnone1easilycontrolled2difficultcontrolled3hepatoencephalopathynone1moderate2severe3nutritionalstategood1moderate2poor3A5-8B9-11C12-15肝功能分级标准（1983年分级标准）IIIIIISGPT正常<2倍正常值>2倍正常值白蛋白>3.5g2.5-3.5g<2.5g胆红素<1.2mg1.2-2.0mg>2.0mg腹水-少量、易控大量脑病-III沉血酶元时间正常延长3-6秒延长6秒以上血管栓塞术冠状静脉栓塞胃短静脉栓塞脾动脉栓塞曲张静脉栓塞脾

7、肿大、脾亢的外科治疗脾切除脾A部分栓塞顽固性腹水的治疗腹腔、上下腔V.转流术Leeven氏管Dever氏管门脉高压症手术并发症创面出血胃肠道出血腹水腹腔感染肠系膜静脉血栓形成肝功能衰竭肝性脑病各种治疗的生存率1year2years5years10yearsPSS89.280.577.067.5Disconection88.782.279.868.1S+D90.385.482.14ChinesJsurg2000;38(2):85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