保留迷走神经主干门奇断流术对门静脉高压症性胃病影响

1、保留迷走神经主干门奇断流术对门静脉高压症性胃病影响 08-07-15 11:00:00 编辑：studa20 作者：吴兴桂 张庆林 王广伟 李颖 谷晓光 刘少飞 【摘要】目的：比较保留迷走神经主干门奇断流术（VTPPD）和贲门周围血管离断术（PD）对门静脉高压性胃病（PHG）的影响。方法：77例门静脉高压患者分为VTPPD和PD两组，VTPPD组36例，PD组41例，术前和术后第3周常规行胃镜检查，并对两组手术前后PHG的发病率、PHG加重病例比率分别予以比较。结果：两组食道胃底静脉曲张皆明显减轻或消失。VTPPD组术前PHG发病率为55.6%(20/36)，术后为69.4%(25/36)，手

2、术前后发病率差异无统计学意义（P=0.224）;PD组术前伴PHG者61.0%(25/41)，术后PHG为87.8%(36/41)，手术前后差异有统计学意义（P=0.005）。手术后VTPPD组PHG发病率低于PD组（P=0.048）。PHG程度加重者VTPPD组8例（22.2%,8/36）,PD组19例（46.3%,19/41），发生率差异有统计学意义（P=0.027）。结论：VTPPD较传统的断流术明显减少PHG的发病率，并可明显减轻加重程度。 【关键词】门静脉高压性胃病门奇断流术迷走神经 The effect of pericardial devascularization with v

3、agustrunk preservation on portal hypertension gastropathy 【ABSTRACT】Objective:To probe the different influence of pericardial devascularization by preserving vagus trunk(VTPPD) and pericardial devascularization (PD) on portal hypertensive gastropathy (PHG).Methods:77 patients with portal hypertensio

4、n were divided into VTPPD and PD group,the VTPPD group included 36 cases,and PD group included 41 cases.Varices of esophagus and fundus of stomach and PHG were observed by gastroscopy before and 3 weeks after operation in all cases,and compared postoperative incidence of PHG in the 2 groups.Results:

5、In all cases,Varices of esophagus and fundus of stomach disappeared or relieved obviously.The incidence of PHG in VTPPD group before operation was 55.6%(20/36),and that after operation was 69.4%(25/36),the former was not higher statistically(P=0.224);the incidence of PHG in PD group before operation

6、 was 61.0%(25/41),and that after operation was 87.8%(36/41),the former was not higher than the latter statistically(P=0.005);and the postoperative incidence of PHG in PD group was higher significantly than that in VTPPD group (P=0.048).There were 8(22.2%,8/36)patients whose degree of PHG aggravated

7、in VTPPD group,and there were 19(46.3%,19/41)patients whose degree of PHG aggravated in PD group,the rate of the former was significantly lower than that of the latter(P=0.027).Conclusion:Comparing with the classic portoazygous devascularization,VTPPD can reduce the incidence and the degree of PHG.

8、【KEY WORDS】Portal hypertensive gastropathyPericardial devascularizationVagus nerve 从2000年9月至2005年3月，我们收治门静脉高压病人77例，其中36例采用保留迷走神经主干门奇断流术（VTPPD），41例采用传统的贲门周围血管离断术（PD），观察两种术式对门静脉高压症性胃病（PHG）的影响。 1 资料和方法 1.1 一般资料 77例皆为肝炎后肝硬化所致门静脉高压，不包括急诊手术病例。术前常规作胃镜检查，对病人有无PHG，病变的范围及程度详细记录。将病人分为保留迷走神经主干门奇断流术（VTPPD）组及贲门周围

9、血管离断术（PD）组。VTPPD组36例，男31例，女5例，年龄2658岁，平均38.5岁。有出血史25例，ChildA级17例，B级19例；食管胃底静脉曲张（严重程度按stiegmann分级）1、度6例，、度30例。PHG（严重程度按McCormack方法）2轻度（马赛克征、小红点征或轻度红色改变）13例，重度（红斑征、红色牛肉样改变或黑棕色斑）7例。PD组41例，男 31例，女9例，年龄2961岁，平均40.3岁。有出血史29例；肝功能Child A级22例，B级19例；食管胃底静脉曲张、度14例，、度27例；PHG轻度17例，重度8例。 1.2 方法 VTPPD手术方法：常规切除脾脏和游

10、离胃底，小弯侧从鸦爪神经上方开始紧贴胃壁分束结扎迷走神经分支、小网膜及其伴随的血管。小弯侧游离至贲门下1cm时斜向His角，剪开浆膜层和食管左外侧后腹膜 ，用小弯钳紧贴肌层游离，保留迷走神经前后主干、肝支与腹腔支神经。翻起胃后壁，离断冠状静脉的胃支、食管支、高位食管支及胃后壁组织，包括迷走神经分支与血管，直至贲门上食管710cm,使上半胃及食管完全游离。间断缝合小弯侧前后壁浆肌层，使其浆膜化。 PD手术按常规进行。 两组病例皆在术后第3周复查胃镜，详细记录PHG及食道胃底静脉曲张的范围及程度。 2 结 果 2.1 术后一般情况 两组患者术后皆顺利恢复，未出现肝性脑病、术后消化道出血等严重并发症。 2.2 食道胃底静脉曲张与PHG 术后第3周复查胃镜，两组食道胃底静脉曲张皆明显减轻或消失。 PHG：VTPPD组36例中，术前伴PHG者20例（55.6%），术后PHG25例（69.4%），手术前后差异无统计学意义（2=1.48,P=0.224）;PD组41例患者中，术