改良腹腔镜下脾脏切除及贲门周围血管离断术在门静脉高压症中的临床应用研究

发布时间：2018-04-11 19:03

本文选题：门静脉高压症 + 腹腔镜　；参考：《华中科技大学》2015年博士论文

【摘要】：目的： 1.对比传统开腹脾切除及贲门周围血管离断术,观察腹腔镜脾切除及贲门周围血管离断术(Laparoscopic Splenectomy plus pericardial Devascularization, LSPD)的临床效果(可行性、安全性和有效性)。 2.观察改良LSPD通过对手术的简化和改进对门静脉高压症的治疗效果,探讨减少术中出血,提高手术成功率的策略。 3.完善并总结改良LSPD的合理的操作流程,建立LSPD的手术规范。方法：自2012年6月-2015年1月本中心149例门静脉高压症患者行LSPD,110例行开腹脾切除及贲门周围血管离断术(open splenectomy plus pericardial devascularization,OSPD),腹腔镜手术患者按时间及脾脏大小分层,A组：比较行LSPD的149例患者(Group LSPD, GLS)与行OSPD的110例患者(Group OSPD, GOS); B组：比较46例行传统LSPD的早期病例(Group Earlier Stage, ES)与103例行改良LSPD的后期病例(Group Later Stage, LS);C组：比较103例LS中脾脏长径大于20cm的39例巨脾病例(MS,Group massive splenomegaly)与脾脏长径小于20cm的64例非巨脾病例(NMS,Group non-massive splenomegaly)。采用回顾性分析方法,分别比较各组患者的临床资料,术前相关资料包括：年龄、性别、病因、肝功能分级、脾脏长径等；术中及术后资料包括：手术时间、术中失血量、术后进食时间、术后住院时间、术后并发症发生率、手术中转率及术后随访情况等。并对上述指标进行统计学分析：结果以均数±标准差(M±SD)形式表示。对计量资料,常规验证正态性并运用t检验;对于计数资料,常规验证方差齐性,数据分析选用卡方检验(x2检验)或Fisher确切概率法,等级资料用非参数检验(Mann-Whitney U),检验水准定为a=0.05,当p0.05是认为差异有统计学意义。所有数据均采用SPSS19.0进行分析。结果： A组所有患者手术均获成功,无一例围手术期死亡,术后所有患者均康复出院,术后随访半年内无明显并发症。GLS中转开腹4例(中转率2.68%)。GLS组的平均手术时间长于GOS组(344.16min vs241.73min,p=0.027),而GLS组术中出血量(793.25ml vs914.54ml,p=0.009)、术后进食时间(42.66hvs56.25h,p=0.011)、术后住院时间(7.5d vs8.93d, p=0.043)均较GOS明显减少(p0.05),术后并发症发生率(p0.05)无统计学意义。 B组ES中有3例及LS中有1例中转开腹手术,其余146例均顺利完成LSPD,无围手术期死亡或二次手术,术后均康复出院,随访半年内无明显并发症。ES的平均手术时间长于LS (344.2min vs214.3min, p0.05),而术中出血量多于LS(907.4ml vs715.3ml,p0.05)。LS组术后进食时间(7.6d vs9.1d, p0.05)及术后住院时间(41.3h vs51.2h,p0.05)短于ES组。术后并发症发生率(4.85%vs10.8%,p0.05)及手术中转率(0.97%vs6.52%,p0.05)LS组明显少于ES组。 C组MS中有1例中转开腹手术,其余102例均顺利完成改良LSPD,MS的平均手术时间长于NMS (246.5min vs184.3min, p0.05),而术中出血量(876.4ml vs492.5ml, p0.05)及手术中转率(2.56%vs0%,p0.05)多于NFS。两者在术后进食时间(41.2h vs40.4h,p0.05)、术后住院时间(7.9d vs7.1d,p0.05)以及并发症发生率(5.13%vs4.68%,p0.05)无显著差异。结论： 1.门静脉高压症患者行改良LSPD是安全有效的,比传统开腹手术的术中出血量少、术后恢复进食早、术后住院时间短,具有明显的微创优势。 2.改良LSPD采用建立脾蒂隧道和食管后隧道的技术,对手术进行的简化和改进可以明显缩短手术时间、减少术中出血量、加快术后胃肠道恢复、降低住院天数、降低术后并发症发生率及手术中转率,明显可以提高手术的安全性及疗效。 3.巨脾、重度静脉曲张不是腹腔镜手术的绝对禁忌证,在经验丰富的中心并熟练掌握腔镜技术的条件下可以选择性开展。 4.合理的操作流程、标准的手术规范和改良LSPD对手术进行的简化和改进可以提高手术的可实施性与成功率,有助于改良LSPD在门静脉高压症中的推广。
[Abstract]:Purpose :

1 . To compare the clinical effects ( feasibility , safety and effectiveness ) of laparoscopic splenic resection plus pericardial devascularization ( LSPD ) by comparing the traditional open - abdominal splenic resection and the pericardial devascularization .

2 . To observe the effect of modified LSPD on portal hypertension by simplifying and improving operation , and to discuss the strategy of reducing intraoperative hemorrhage and improving the success rate of operation .

3 . To perfect and summarize the reasonable operation flow of LSPD and establish the operation specification of LSPD .

Method :

From June 2012 to Jan . 2015 , 149 patients with portal hypertension were treated with LSPD , 110 patients with open cholecystectomy plus pericardial devascularization ( OSPD ) and 110 patients ( Group OSPD , GOS ) in group A : 149 patients with LSPD ( Group LSPD , GLS ) and 103 patients with OSPD were compared . A retrospective analysis method was used to compare the clinical data of each group , including age , sex , etiology , liver function grade , spleen length and so on .
The operative and postoperative data included : operative time , intraoperative blood loss , postoperative feeding time , postoperative hospital stay , incidence of postoperative complications , rate of operation and follow - up , etc . The results were statistically analyzed by mean 卤 standard deviation ( M 卤 SD ) .

Results :

The average operative time of GLS group was longer than that in GOS group ( 344.16min vs 241.73min , p = 0 . 009 ) , and that of GLS group was shorter than GOS group ( 344.16min vs 241.73min , p = 0 . 009 ) , and the postoperative hospital stay time ( 7.5d vs 8.93d , p = 0.043 ) decreased significantly ( p = 0 . 05 ) .

In group B , there were 3 cases in group B and one in LS , and the other 146 cases successfully completed LSPD without perioperative death or secondary operation . The average operative time of ES was longer than LS ( 344.2 min vs 214 . 3 min , p < 0.05 ) , and the mean operative time was more than LS ( 77.4 ml vs 715.3 ml , p . 05 ) . The incidence of postoperative complications ( 4.85 % vs 10.8 % , p 0.05 ) and the rate of operation ( 0.97 % vs 6.52 % , p < 0.05 ) were significantly lower than those of ES group .

The average operative time of MS was longer than that of NMS ( 246.5 min vs 184.3 min , p < 0.05 ) . The average operative time of the operation was longer than that in NMS ( 246.5 min vs 184.5 min , p < 0.05 ) . The operative time of operation was ( 46.4 ml vs 492.5 ml , p 0.05 ) , and the rate of complications ( 5.13 % vs 7.1d , p0.05 ) and complication rate ( 5.13 % vs 4.68 % , p0.05 ) were not significant .

Conclusion :

1 . LSPD is safe and effective in patients with portal hypertension . Compared with the traditional open operation , the LSPD is safe and effective . It has the advantages of less bleeding during operation , early postoperative recovery , short hospitalization time and obvious minimally invasive advantage .

2 . The improved LSPD can shorten the operation time , reduce the intraoperative blood loss , accelerate the recovery of the gastrointestinal tract after operation , reduce the number of days of hospitalization , reduce the incidence of postoperative complications and the rate of operation , and obviously improve the safety and efficacy of the operation .

3 . The absolute contraindications of giant spleen and severe varsity are not absolute contraindications for laparoscopic surgery , and can be carried out selectively under the conditions of experienced centers and mastering the endoscopic techniques .

4 . Reasonable operation procedure , standard operation specification and improved LSPD can improve the feasibility and success rate of operation , which can improve the popularization of LSPD in portal hypertension .

【学位授予单位】：华中科技大学
【学位级别】：博士
【学位授予年份】：2015
【分类号】：R657.34

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