保留迷走神經(jīng)主干門奇斷流術(shù)對門靜脈高壓癥性胃病影響

1、保留迷走神經(jīng)主干門奇斷流術(shù)對門靜脈高壓癥性胃病影響         08-07-15 11:00:00     編輯：studa20           作者：吳興桂 張慶林 王廣偉 李穎 谷曉光 劉少飛 【摘要】目的：比較保留迷走神經(jīng)主干門奇斷流術(shù)（VTPPD）和賁門周圍血管離斷術(shù)（PD）對門靜脈高壓性胃病（PHG）的影響。方法：77例門靜脈高壓患者分為VTPPD和PD兩組，

2、VTPPD組36例，PD組41例，術(shù)前和術(shù)后第3周常規(guī)行胃鏡檢查，并對兩組手術(shù)前后PHG的發(fā)病率、PHG加重病例比率分別予以比較。結(jié)果：兩組食道胃底靜脈曲張皆明顯減輕或消失。VTPPD組術(shù)前PHG發(fā)病率為55.6%(20/36)，術(shù)后為69.4%(25/36)，手術(shù)前后發(fā)病率差異無統(tǒng)計學(xué)意義（P=0.224）;PD組術(shù)前伴PHG者61.0%(25/41)，術(shù)后PHG為87.8%(36/41)，手術(shù)前后差異有統(tǒng)計學(xué)意義（P=0.005）。手術(shù)后VTPPD組PHG發(fā)病率低于PD組（P=0.048）。PHG程度加重者VTPPD組8例（22.2%,8/36）,PD組19例（46.3%,19/41），發(fā)

3、生率差異有統(tǒng)計學(xué)意義（P=0.027）。結(jié)論：VTPPD較傳統(tǒng)的斷流術(shù)明顯減少PHG的發(fā)病率，并可明顯減輕加重程度。    【關(guān)鍵詞】門靜脈高壓性胃病門奇斷流術(shù)迷走神經(jīng)      The effect of pericardial devascularization with vagustrunk preservation on portal hypertension gastropathy    【ABSTRACT】Objective:To probe the different i

4、nfluence of pericardial devascularization by preserving vagus trunk(VTPPD) and pericardial devascularization (PD) on portal hypertensive gastropathy (PHG).Methods:77 patients with portal hypertension were divided into VTPPD and PD group,the VTPPD group included 36 cases,and PD group included 41 case

5、s.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:In all cases,Varices of esophagus and fundus of stomach disappeared or relieved obviously.The incidenc

6、e 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 was 61.0%(25/41),and that after operation was 87.8%(36/41),the former was not higher than the latter

7、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 in VTPPD group,and there were 19(46.3%,19/41)patients whose degree of PHG aggravated in PD group,the r

8、ate 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.    【KEY WORDS】Portal hypertensive gastropathyPericardial devascularizationVagus nerve&#

9、160;   從2000年9月至2005年3月，我們收治門靜脈高壓病人77例，其中36例采用保留迷走神經(jīng)主干門奇斷流術(shù)（VTPPD），41例采用傳統(tǒng)的賁門周圍血管離斷術(shù)（PD），觀察兩種術(shù)式對門靜脈高壓癥性胃?。≒HG）的影響。    1  資料和方法    1.1  一般資料  77例皆為肝炎后肝硬化所致門靜脈高壓，不包括急診手術(shù)病例。術(shù)前常規(guī)作胃鏡檢查，對病人有無PHG，病變的范圍及程度詳細(xì)記錄。將病人分為保留迷走神經(jīng)主干門奇斷流術(shù)（VTPPD）組及賁門周圍血管離斷術(shù)（PD）組。V

10、TPPD組36例，男31例，女5例，年齡2658歲，平均38.5歲。有出血史25例，ChildA級17例，B級19例；食管胃底靜脈曲張（嚴(yán)重程度按stiegmann分級）1、度6例，、度30例。PHG（嚴(yán)重程度按McCormack方法）2輕度（馬賽克征、小紅點(diǎn)征或輕度紅色改變）13例，重度（紅斑征、紅色牛肉樣改變或黑棕色斑）7例。PD組41例，男 31例，女9例，年齡2961歲，平均40.3歲。有出血史29例；肝功能Child A級22例，B級19例；食管胃底靜脈曲張、度14例，、度27例；PHG輕度17例，重度8例。    1.2  方法 

11、VTPPD手術(shù)方法：常規(guī)切除脾臟和游離胃底，小彎側(cè)從鴉爪神經(jīng)上方開始緊貼胃壁分束結(jié)扎迷走神經(jīng)分支、小網(wǎng)膜及其伴隨的血管。小彎側(cè)游離至賁門下1cm時斜向His角，剪開漿膜層和食管左外側(cè)后腹膜 ，用小彎鉗緊貼肌層游離，保留迷走神經(jīng)前后主干、肝支與腹腔支神經(jīng)。翻起胃后壁，離斷冠狀靜脈的胃支、食管支、高位食管支及胃后壁組織，包括迷走神經(jīng)分支與血管，直至賁門上食管710cm,使上半胃及食管完全游離。間斷縫合小彎側(cè)前后壁漿肌層，使其漿膜化。    PD手術(shù)按常規(guī)進(jìn)行。    兩組病例皆在術(shù)后第3周復(fù)查胃鏡，詳細(xì)記錄PHG及食道胃底靜脈曲張的范圍及程度。    2  結(jié)  果    2.1  術(shù)后一般情況  兩組患者術(shù)后皆順利恢復(fù)，未出現(xiàn)肝性腦病、術(shù)后消化道出血等嚴(yán)重并發(fā)癥。    2.2  食道胃底靜脈曲張與PHG  術(shù)后第3周復(fù)查胃鏡，兩組食道胃底靜脈曲張皆明顯減輕或消失。    PHG：VTPPD組36例中，術(shù)前伴PHG者20例（55.6%），術(shù)后PHG25例（69.4%），手術(shù)前后差異無統(tǒng)計學(xué)意義（2=1.48,P=0