Sriussadaporn Suvit, Pak-art Rattaplee, Sriussadaporn Sukanya
Department of Surgery, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.
J Med Assoc Thai. 2004 Apr;87(4):427-31.
Portosystemic shunts remain to be a good means for preventing recurrent variceal hemorrhage in a certain number of patients who fail to respond to other therapeutic modalities. Total portal decompression is no longer recommended owing to the high incidence of postoperative encephalopathy and liver failure. Distal splenorenal shunt is too technically demanding. A small-diameter H-graft portacaval shunt (SDHGPCS) which partially decompresses the portal system and was popularized by Sarfeh et al and associates in 1983 seems to be a good alternative for its simplicity to construct and impressive results.
SDHGPCS with an 8 mm. PTFE graft has been performed to prevent recurrent variceal hemorrhage in cirrhotic patients who failed to respond to long term pharmacotherapy and endoscopic therapy during the last 3 years at our institution. Data analysis included: causes of cirrhosis, patients' Child-Pugh classification, operative time, operative blood transfusion, and results of treatment.
Nine cirrhotic patients were entered into the present study. Three patients (33.3%) were in Child-Pugh class A and 6 (66.7%) were in Child-Pugh class B. Three patients had ringed PTFE grafts and 6 had non-ringed PTFE grafts. The operative time ranged from 225 to 420 minutes (mean 303, median 285 minutes). There was no perioperative (30 days) death. One postoperative intraabdominal hemorrhage was successfully treated by relaparotomy. Two patients were lost to follow up at 3 and 10 months after the operations. Four patients are alive and well at 12, 24, 30 and 35 months after the operations. One patient developed hepatic encephalopathy at 35 months postoperation which was thought to be secondary from progression of the hepatic parenchymal disease. One patient developed recurrent variceal hemorrhage at 30 months postoperation from portal vein thrombosis and was successfully treated by endoscopic variceal sclerotherapy (EVS). One patient died from carcinoma of the larynx 3 months after SDHGPCS and 2 died from end stage liver disease at 30 and 45 months after SDHGPCS.
SDHGPCS is an effective mean to prevent recurrent variceal hemorrhage. The procedure is simple and practical to perform in hospitals with low volume of portosystemic shunt operations. The authors recommended SDHGPCS as an alternative in prevention of recurrent variceal hemorrhage in cirrhotic patients who fail to respond to other therapeutic modalities.
对于一些对其他治疗方式无反应的患者，门体分流术仍是预防复发性静脉曲张出血的有效方法。由于术后肝性脑病和肝衰竭的发生率较高，目前不再推荐进行全门静脉减压术。远端脾肾分流术技术要求过高。1983年由萨菲等人推广的一种小直径H型移植门腔分流术（SDHGPCS），可部分降低门静脉压力，因其操作简单且效果显著，似乎是一个不错的选择。
在过去3年里，我们机构对那些对长期药物治疗和内镜治疗无反应的肝硬化患者实施了带8毫米聚四氟乙烯移植物的SDHGPCS，以预防复发性静脉曲张出血。数据分析包括：肝硬化病因、患者的Child-Pugh分级、手术时间、术中输血情况及治疗结果。
9例肝硬化患者纳入本研究。3例（33.3%）为Child-Pugh A级，6例（66.7%）为Child-Pugh B级。3例患者使用带环聚四氟乙烯移植物，6例使用无环聚四氟乙烯移植物。手术时间为225至420分钟（平均303分钟，中位数285分钟）。围手术期（30天）无死亡病例。1例术后腹腔内出血通过再次剖腹手术成功治疗。2例患者在术后3个月和10个月失访。4例患者在术后12、24、30和35个月时情况良好。1例患者在术后35个月发生肝性脑病，被认为是肝实质疾病进展所致。1例患者在术后30个月因门静脉血栓形成发生复发性静脉曲张出血，通过内镜下静脉曲张硬化治疗（EVS）成功治疗。1例患者在SDHGPCS术后3个月死于喉癌，2例在SDHGPCS术后30个月和45个月死于终末期肝病。
SDHGPCS是预防复发性静脉曲张出血的有效方法。该手术在门体分流手术量较少的医院实施简单且实用。作者推荐SDHGPCS作为对其他治疗方式无反应的肝硬化患者预防复发性静脉曲张出血的一种选择。
