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冠腔分流联合脾切除术在门静脉高压症中的应用价值
DOI: 10.3969/j.issn.1001-5256.2021.04.034
Value of coronary-caval shunt combined with splenectomy in portal hypertension
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图 1 4例冠腔分流术中情况[两种方式(直接吻合或架桥吻合)和两种路径(肝十二指肠韧带或结肠系膜下方冠腔分流)]
注：a，扩张的胃冠状静脉；b，充分游离胃冠状静脉并离断入门静脉端，修整胃冠状静脉近端口，备冠腔直接吻合用；c，修整好的胃冠状静脉近端口与肝十二指肠韧带背侧下腔静脉左侧缘，直接行端侧吻合术；d，充分游离下腔静脉，暴露2/3下腔静脉前壁；e，肝十二指肠韧带下方人工血管架桥冠腔分流术；f，结肠系膜下方人工血管架桥冠腔分流术。
图 2 冠腔分流术的两种方式和两种路径的手术模式图
注：a，指胃冠状静脉远端离断，行冠腔直接吻合术；b，指胃冠状静脉远端离断，选择肝十二指肠韧带背侧下腔静脉左侧缘，采用人工血管或自体静脉(脾静脉、大隐静脉等)架桥行冠腔分流术；c，指胃冠状静脉远端离断，选择十二指肠横部下方下腔静脉处，采用人工血管或自体静脉(脾静脉、大隐静脉等)架桥行冠腔分流术。
图 3 冠腔分流术前术后典型影像学改变
注：a，术前胃镜可见重度食管胃底静脉曲张；b~c，术前上腹部增强CT可见扩张的胃冠状静脉和食管胃底静脉重度曲张；d，冠腔分流术后复查架桥的人工血管通畅；e，术后随访复查胃镜可见食管胃底静脉曲张显著减轻，静脉球消失；f~g，术后随访复查上腹部增强CT可见食管胃底静脉曲张显著减轻。
表 1 4例冠腔分流患者的临床资料
患者编号 性别 年龄(岁) 传染病 诊断 手术方式 随访(月) 人工血管内径(mm) 人工血管血流速度(cm/s) 1 男 24 乙型肝炎 门静脉高压症，食管胃底静脉重度曲张，巨脾伴脾功能亢进 脾切+冠腔人工血管分流术 5 7.7 66 2 女 46 乙型肝炎 门静脉高压症，食管胃底静脉重度曲张并出血，脾大脾功能亢进 冠腔直接吻合分流术 6 3 女 33 乙型肝炎 门静脉高压症，食管胃底静脉重度曲张并出血，脾功能亢进 脾动脉结扎+冠腔人工血管分流术 57 8.5 53 4 女 35 无 特发性门静脉高压症并上消化道出血，门静脉海绵样变性，脾大脾功能亢进 脾切+冠腔人工血管分流术 13 12.0 60 
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表 2 4例冠腔分流患者的手术情况、术后住院时间及手术前、后白细胞和血小板的变化
患者编号 手术时间(min) 术中出血量(ml) 术前白细胞(×109/L) 术后白细胞(×109/L) 术前血小板计数(×109/L) 术后血小板计数(×109/L) 术后住院时间(d) 1 300 500 1.9 6.3 20.0 312.0 22 2 240 300 2.6 6.3 54.0 44.0 14 3 280 50 1.8 3.8 52.0 65.0 15 4 250 100 0.8 3.9 31.0 290.0 20
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