丙肝肝硬化患者脾切除术后抗病毒治疗的综合评价

发布时间：2018-03-14 00:04

  本文选题：慢性丙肝　切入点：肝硬化　出处：《第四军医大学》2014年硕士论文　论文类型：学位论文

【摘要】：丙型肝炎是由丙型肝炎病毒（Hepatitis C virus，HCV）引起的一种隐匿性、持续性、进展性疾病，呈世界性流行。全球约有3.2%丙肝感染率，感染人数约1.7亿，我国达4000万以上[1]。由于感染HCV后临床表现无特异性，多数患者就诊时已发展为肝硬化，并发脾脏肿大、脾功能亢进、血细胞下降等临床综合症状，严重影响了干扰素抗病毒方案的实施。目前针对脾亢问题，通过非手术治疗难以控制，无特异性药物有效遏制，极易造成白细胞和血小板减少，甚至导致的出血现象。结合外科手术和介入治疗手段，主要包括脾脏切除、脾脏部分切除、介入下脾动脉栓塞治疗等，可以解决或部分解决脾大脾亢问题。然而，脾脏作为重要的外周免疫器官具有抗感染免疫功能，国外有学者提出最大限度保留脾脏功能及脾组织，不主张切脾治疗，对此学界至今仍然存在争议。 随着近年来丙肝抗病毒治疗有效率的提高，丙肝肝硬化伴脾功能亢进患者术后远期生存质量和各项指标的提高，与是否抗病毒治疗有关成为研究热点。脾功能亢进不仅严重影响白细胞和血小板下降，出现凝血功能障碍和出血倾向，而且对患者的身心健康产生负面作用。肝硬化的形成与脾脏复杂的免疫调节机制有着密切关系，其免疫因子的变化间接参与了肝纤维化的进程[5-6]。门静脉系统阻力和侧枝分流的增加也是促进脾功能亢进发生的重要因素[7]，因此，越来越多的证据表明脾亢、肝硬化、门静脉高压症三者互为因果，不单纯是肝硬化的继发病变，且给予肝炎肝硬化脾切除患者抗病毒治疗不仅可行，而且将从抗病毒治疗中获得益处[18]。 本课题主要以回顾2000年1月至2012年5月，第四军医大学和西安交通大学共四所附属医院收治的丙型肝炎肝硬化伴脾功能亢进且是否行脾切除术治疗的患者共155例为研究对象（脾切治疗97例、保脾治疗58例），其一观察肝硬化患者脾切除术后行抗病毒治疗（抗病毒治疗组42例和未抗病毒治疗组33例）对患者凝血指标、肝脏储备功能及门脉高压的动态临床影响；其二以5年为随访节点，采用生存质量综合评定问卷（WHOQOL—BREF）等测定，，对丙型肝炎肝硬化伴脾功能亢进患者（脾切除术组28例和保脾治疗组30例）生存质量(quality of life，QOL)状况进行调查，并评价聚乙二醇干扰素α-2a联合利巴韦林抗病毒治疗对患者QOL的干预作用。 结果如下： 1.PT在治疗组中的表达于术后60个月较抗病毒治疗前显著降低（P＜0.01），延缓了PT时间； APTT治疗组和对照组在术后均即刻出现下降（P＜0.05），但这种下降趋势于治疗组可保持到术后60个月，而对照组自术后6个月以后呈上升趋势；治疗组对PTA短期无改善，但术后60个月时较对照组具有显著差异（P＜0.01）；术后6月时治疗组和对照组Fib值均为最高点，且治疗组与各时间点均无显著差异；PLT在术后即刻升高且差异显著（P0.001），并随病程延长与ALB水平和A/G比值同样较术前均呈降低趋势。治疗组较对照组能够使术后降低的门脉宽度值延缓上升。 2．比较患者自身健康状况的四个方面，包括主观感觉、生理情况、心理状态、社会关系，发现脾切组与保脾组整体5年生存质量无差异；而单纯行脾切组5年生存质量较保脾并抗病毒治疗组差，但脾切组术后联合抗病毒治疗可有效地提高患者术后5年生存质量，其差异均具有统计学意义。 综上所述； 脾脏切除后无论是否出现免疫功能变化，仍可间接改善肝脏储备功能、延缓肝硬化进程、促进肝细胞再生，但疗效短暂。若能术后联合抗病毒治疗对肝硬化患者肝脏储备功能、出凝血稳定/保护作用、延缓门静脉宽度扩张及更有效改善5年生存质量意义更大。
[Abstract]:Hepatitis C is by hepatitis C virus (Hepatitis C, virus, HCV) an occult, caused by persistent, progressive disease is a worldwide epidemic. There are around 3.2% HCV infection rate, the infection number about 170 million, China is more than 40 million [1]. after HCV infection due to lack of specific clinical manifestations, the majority of patients treatment has been developed for concurrent cirrhosis, splenomegaly, hypersplenism, clinical symptoms of blood cells decreased, serious impact on the implementation of the scheme. The antiviral hypersplenism treated by non operative problems, it is difficult to control, no effective containment of specific drugs, extremely easy to cause neutropenia and thrombocytopenia, and even lead to bleeding the phenomenon. The combination of surgical and interventional treatment, including surgical resection, partial resection of the spleen, interventional splenic artery embolization treatment, can solve or partially solve problems of splenomegaly and hypersplenism. However, spleen As an important peripheral immune organ, the spleen has the function of anti infection and immunity. Scholars from abroad have proposed that the spleen function and splenic tissue can be maximally preserved, and no splenic treatment is advocated.
As to improve the efficiency of antiviral therapy for hepatitis C in recent years, patients with hepatitis C cirrhosis with hypersplenism after long-term survival and quality indicators improved, and whether the antiviral therapy has become a research hotspot. Hypersplenism not only affects white blood cells and platelets decreased, coagulation dysfunction and bleeding tendency, but also have a negative effect on patients the physical and mental health. The formation of spleen and liver cirrhosis complicated immune regulation mechanism is closely related to the changes of immune factors indirectly involved in the process of liver fibrosis [5-6]. portal system shunt resistance and collateral increase is an important factor for the occurrence of hypersplenism [7], therefore, more and more evidence of liver cirrhosis, hypersplenism and portal portal hypertension is not only the three reciprocal causation of cirrhosis, secondary lesions, and give the patients resistant hepatitis cirrhosis splenectomy Drug treatment is not only feasible, but will benefit from antiviral treatment, [18].
This paper focuses on a review from January 2000 to May 2012, a total of four hepatitis C cirrhosis from the Affiliated Hospital of The Fourth Military Medical University and the Xi'an Jiao Tong University with hypersplenism and whether splenectomy in the treatment of patients with a total of 155 cases as the research object (spleen resection in the treatment of 97 cases, 58 cases of the treatment, the observation of spleen preserving) in patients with liver cirrhosis after splenectomy (antiviral therapy the antiviral treatment group of 42 cases and no antiviral treatment group 33 cases) on blood coagulation indexes of patients with clinical effect, dynamic liver function and portal hypertension; second in 5 years of follow-up by the node, the quality of life assessment questionnaires (WHOQOL - BREF) were of hepatitis C patients with cirrhosis and hypersplenism (splenectomy group and 28 cases of spleen preserving treatment group 30 cases (quality of life) quality of life, QOL) to investigate the situation, and evaluation of pegylated interferon alpha -2a combined with ribavirin The intervention of treatment on patients with QOL.
The results are as follows:
The expression of 1.PT in the treatment group after 60 months compared with before antiviral therapy significantly decreased (P < 0.01), the PT time delay; APTT treatment group and control group after operation were immediately decreased (P < 0.05), but the decline in the treatment group can be maintained up to 60 months after operation, while the control group after 6 months later showed an upward trend; the treatment group had no improvement on PTA in the short term, but 60 months after operation compared with the control group with significant difference (P < 0.01); after June when the value was the highest point of the treatment group and the control group Fib, and there was no significant difference the treatment group and each time point; PLT in the immediate postoperative period significantly increased (P0.001), and with the extension of the course and the level of ALB and A/G ratio as compared with the preoperative decreased. The treatment group than the control group to the postoperative portal vein width decreased slow rise.
Four aspects of 2. patients with their own health status, including subjective feeling, physiological, psychological status, social relations, found that splenectomy and spleen preserving group overall 5 year survival quality has no difference; and underwent splenectomy group 5 years survival quality and spleen preserving antiviral therapy group, but splenectomy group after antiviral therapy can effectively improve the quality of life of patients after 5 years, the differences were statistically significant.
In summary锛

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