Villeneuve J P, Pomier-Layrargues G, Duguay L, Lapointe R, Tanguay S, Marleau D, Willems B, Huet P M, Infante-Rivard C, Lavoie P
Ann Surg. 1987 Jul;206(1):48-52. doi: 10.1097/00000658-198707000-00007.
Emergency portacaval shunt for variceal bleeding is associated with a high operative mortality, particularly if used as a last resort. Because of this, a strong case has been made against emergency shunt. This report describes an experience with emergency portacaval shunt for the treatment of variceal bleeding when used systematically after hemodynamic stabilization and control of the bleeding episode with balloon tamponade, if necessary, in patients with mild or moderate liver disease. The population studied comprised 62 consecutive patients who rebled from varices while participating in a controlled trial of propranolol for the prevention of rebleeding. Of the 62 patients, nine died of massive hemorrhage and 53 survived the hemorrhage. Of the 53 survivors, 11 had severe liver disease and were not considered for shunt surgery. Of the remaining 42 patients with mild or moderate liver disease, 36 had emergency central portacaval shunt. The interval between endoscopic diagnosis of variceal bleeding and surgery averaged 19 +/- 3 hours (mean +/- SE). The operative mortality rate, defined as in-hospital mortality, was 19%. One- and 2-year survival rates were 78% and 71%, respectively. The incidence of postoperative hepatic encephalopathy was 36%; all patients responded favorably to protein restriction and lactulose. Thus, under specific conditions, emergency portacaval shunt results in an acceptable long-term survival rate. In patients with mild or moderate liver disease, emergency portacaval shunt should be considered when other forms of treatment for the prevention of variceal rebleeding have failed.
用于治疗静脉曲张破裂出血的急诊门腔分流术手术死亡率很高，尤其是在作为最后手段使用时。因此，人们强烈反对进行急诊分流术。本报告描述了在血流动力学稳定且必要时用球囊压迫控制出血发作后，对轻度或中度肝病患者系统性地使用急诊门腔分流术治疗静脉曲张破裂出血的经验。所研究的人群包括62例在参与普萘洛尔预防再出血对照试验期间静脉曲张再次出血的连续患者。62例患者中，9例死于大出血，53例在出血后存活。在53例幸存者中，11例有严重肝病，未考虑进行分流手术。在其余42例轻度或中度肝病患者中，36例行急诊中心门腔分流术。静脉曲张破裂出血内镜诊断与手术之间的间隔平均为19±3小时（均值±标准误）。手术死亡率（定义为住院死亡率）为19%。1年和2年生存率分别为78%和71%。术后肝性脑病的发生率为36%；所有患者对蛋白质限制和乳果糖治疗反应良好。因此，在特定条件下，急诊门腔分流术可带来可接受的长期生存率。对于轻度或中度肝病患者，当预防静脉曲张再出血的其他治疗方法失败时，应考虑进行急诊门腔分流术。
