Bondía J A, Santoyo J, Fernández-Aguilar J L, Marín R, Suarez M A, Caro J A, Jiménez M, Caparrós R, Ribeiro M, de la Fuente A
Servicio de Cirugía Generaly Digestiva, Unidad de Cirugía Hepatobiliar, Hospital Regional, Carlos Haya, Málaga.
Rev Esp Enferm Dig. 1996 Apr;88(4):273-9.
Controversy remains about the best treatment for patients with esophagogastric variceal bleeding. In spite of different therapeutic alternatives and recent progress, such as liver transplantation of TIPS, many patients will finally be treated by standard surgery. With the aim to know the results of surgery in shunting vs non-shunting procedures, we have analyzed a recent and consecutive series of 68 cirrhotics patients operated on for variceal hemorrhage. According to the surgical technique there were three groups: I) 30 patients underwent a total portacaval shunt; II) 18 cases with an azygosportal disconnection; III) 20 patients with a partial portacaval shunt (8-10 mm H-portacaval PTFE graft). All groups were homogeneous considering age, sex etiology, Child-Pugh grade and timing of surgery (elective vs urgent). The complications and mortality rates were similar for the three groups. The overall operative mortality was 10%, and 5% in selected cases (Child-Pugh A-B, non urgent cases). With a follow-up for I, II and III group of 47, 44 and 27 months respectively, chronic encephalopathy have been seen in 61%, 15% and 15% respectively (p < .05). No patient in group I has rebled, and only one case in the II and III groups had a recurrence of hemorrhage. The actuarial three years survival was 76%, 86% and 85% (p NS), and the five year survival was 41% vs 86% for the groups I and II respectively (p < .05). In conclusion, in selected cases, surgery gives excellent immediate and long term results. In patients with variceal bleeding and failure of first line treatments, such as sclerosis or pharmacology, the partial H-portacaval shunt and non-shunting procedures are good alternatives, with low incidence of rebleeding and chronic encephalopathy.
对于食管胃静脉曲张出血患者的最佳治疗方法仍存在争议。尽管有不同的治疗选择以及近期的进展，如经颈静脉肝内门体分流术（TIPS）或肝移植，但许多患者最终仍需接受标准手术治疗。为了解分流手术与非分流手术的治疗效果，我们分析了近期连续收治的68例因静脉曲张出血接受手术的肝硬化患者。根据手术技术分为三组：I组，30例行全门腔分流术；II组，18例行奇静脉断流术；III组，20例行部分门腔分流术（8 - 10mm H型门腔聚四氟乙烯移植物）。三组在年龄、性别、病因、Child-Pugh分级及手术时机（择期手术与急诊手术）方面具有同质性。三组的并发症和死亡率相似。总体手术死亡率为10%，在选择的病例中（Child-Pugh A - B级，非急诊病例）为5%。I、II、III组的随访时间分别为47、44和27个月，慢性脑病的发生率分别为61%、15%和15%（p < 0.05）。I组无患者再出血，II组和III组仅各有1例出血复发。三年预期生存率分别为76%、86%和85%（p无显著性差异），I组和II组的五年生存率分别为41%和86%（p < 0.05）。总之，在选择的病例中，手术能取得良好的近期和长期效果。对于静脉曲张出血且一线治疗（如硬化剂治疗或药物治疗）失败的患者，部分H型门腔分流术和非分流手术是较好的选择，再出血和慢性脑病的发生率较低。
