协和外科课件2.ppt

,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,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 infections,Hypercoagulable,states,Appendicitis,Myeloproliferative,syndrome,Other forms of peritonitisPregnancy,Inflammatory bowel diseaseOral contraceptive drugs,Biliary,tract infectionCollagen diseases,Pancreatitis,Thrombophlebitis,migrans,Postoperative factors Retroperitoneal fibrosis,Splenectomy,Increased portal venous flow,Portosystemic,shunts,Hepatic,arteriovenous,fistulae,Biliary,surgery,Trauma,Unknown,Tumour,invasion and compression,Hepatocellular,carcinoma,Other malignant,tumours,Table1.Number of cases of bleeding,ectopic,varices,reported in the literature.,Sites of,Ectopic,Varices,Number of Reported Cases,Duodenum28,Jejunum and Ileum29,Colon24,Rectum14,Ileostomy,or Colostomy44,Peritoneum16,Common Bile Duct and Gallbladder 3,Vagina 2,Bladder 1,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）,Risk of future bleeding according to,variceal,size.,W.G.RECTOR,Jr,AND T.B.REYNOLDS,Risk of future bleeding according to,variceal,size.,Size of,varices,Small or none Medium Large,13/51 9/41 11/23 0-49,2/34 7/39 13/38 0-6,0/34 4/24 9/17 1-86,0/16 0/24 12/60 12,15/135 30/128 45/138,(11%)(23%)(33%),Follow up,(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,Liver Function(Childs)Classification,Bilirubin,3mg3,albumin,3.5mg1,3-3.5mg2,3.5,g 2.5-3.5g 2.5g,胆红素 2.0mg,腹水 -少量、易控 大量,脑病 -,I II,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,L,eeven,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,1,year 2years 5years 10years,PSS 89.2 80.5 77.0 67.5,Disconection,88.7 82.2 79.8 68.1,S+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,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,手术方式手术死亡率 作者 年代,门-腔分流（急症）42%,Orloff,1984,Sugiura,术 12%,Sugiura,1973,食管下段横断 18%,Cuirent,Hepatology,吻合 吻合 急症33%,择期12%,Sugiura,术 3,.,5-9.7%Sugiura 1988,Warrens 术dsrs 4,.4%,脾-肾分流 1.5%吴光汉等1988,脾-肾分流 8.7%协和,1986,主要手术种类,分流术,近端脾-肾静脉吻合,远端脾-肾静脉吻合,门腔静脉吻合,肠腔静脉吻合,冠状静脉-下腔静脉吻合,门奇静脉阻断术,食道下段贲门周围血管离断术,冠状静脉结扎术,胃底静脉缝扎术,食道下段贲门切除术,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,肝移植,