Belli L, Romani F, Sansalone C V, Aseni P, Rondinara G
Ann Surg. 1986 Mar;203(3):286-91. doi: 10.1097/00000658-198603000-00012.
The development of thrombotic obstruction in the portal bed of cirrhotic patients presents special problems in diagnosis and treatment. In the cirrhotic population treated for portal hypertension at our Surgical Department during the period 1967-1983 (512 patients), the incidence of thrombosis in the portal bed was 16.6% (85 patients). Bleeding was the main presenting symptom (70/85), with a mean of four episodes prior to treatment. Careful angiographic studies and intraoperative evaluation are fundamental steps to determine the exact anatomical involvement, the presence of recanalized veins or fresh occluding clots, and the applicability of shunt procedures. A massive portosplenomesenteric involvement often associated with poor surgical possibilities was found in 19 patients (22.3%). The presence of partially recanalized veins and fresh occluding clot suitable for disobliterative techniques prior to shunt was found in 16 patients, and out of 73 operated patients a total of 55 shunt procedures could be performed. Fifty-three patients who bled from varices could be followed up to 5 years: 39 underwent a shunt procedure with a 51.2% 5-year survival rate, while only one of 14 nonshunted or nonoperated survived up to 3 years, and a lethal bleeding was the cause of death in all but one. Disobliterative techniques (Fogarty thrombectomy and endovenectomy of intimal fibrotic thickenings) prior to shunting provided a good long-term patency rate with a 50% protection from lethal bleeding recurrences. Nonshunt procedures and the extensive involvement of the portal bed are associated with bad prognosis. Also, endoscopic sclerotherapy, attempted in patients with massive thrombosis, could not prevent recurrences and death from bleeding. Despite a 30% failure rate in our study, shunting surgery should be considered the only therapeutical possibility of preventing further thrombotic recurrences and consequent life threatening bleeding episodes.
肝硬化患者门静脉床血栓形成梗阻在诊断和治疗方面存在特殊问题。在1967年至1983年期间于我院外科接受门静脉高压治疗的肝硬化患者群体（512例患者）中，门静脉床血栓形成的发生率为16.6%（85例患者）。出血是主要的首发症状（70/85），治疗前平均出血4次。仔细的血管造影研究和术中评估是确定确切解剖受累情况、再通静脉或新鲜闭塞性血栓的存在以及分流手术适用性的基本步骤。19例患者（22.3%）出现广泛的门静脉脾肠系膜受累，常伴有较差的手术可能性。16例患者发现存在部分再通静脉和适合分流术前采用再通技术的新鲜闭塞性血栓，在73例接受手术的患者中，总共可进行55例分流手术。53例因静脉曲张出血的患者可随访至5年：39例行分流手术，5年生存率为51.2%，而14例未行分流或未手术的患者中只有1例存活至3年，除1例患者外，其余均死于致命性出血。分流术前采用再通技术（Fogarty血栓切除术和内膜纤维性增厚的静脉内膜切除术）可提供良好的长期通畅率，并有50%的保护作用防止致命性出血复发。非分流手术和门静脉床广泛受累与预后不良相关。此外，对大量血栓形成患者尝试的内镜硬化治疗无法预防出血复发和死亡。尽管在我们的研究中有30%的失败率，但分流手术仍应被视为预防进一步血栓复发及随之而来的危及生命的出血发作的唯一治疗选择。
