门静脉高压症脾切除术后持续性发热原因的探讨及处理

摘要：目的 探讨门静脉高压症脾切除术后持续性发热的原因及处理方法。方法 收集13年间295例行门静脉高压症手术伴脾切除术病例的临床资料，对其中80例术后体温高于38.5℃，持续性发热2周以上的发热原因和处理进行分析。结果 除2例发热原因不明外，术后发热均由各种并发症引起，其中门脾静脉血栓形成35例，脾窝积血、积液合并感染20例，左膈下感染7例，肺炎、胸腔积液或积脓5例，术后胰尾部脓肿、泌尿系感染、切口感染各3例，食管吻合口瘘1例，腹腔感染1例。持续性发热与肝功能分级有关(P<0.01)，与术式无关(P>0.05)。门脾静脉血栓形成与术式选择无关(P>0.05)。结论 门脾静脉血栓形成及脾窝积血、积液或感染是术后持续性发热的主要原因。防治各种感染及改善肝功能可有效地减少术后持续性发热。     

Laparoscopic Splenectomy Combined with Revision of Previous Laparoscopic Gastric Bypass

Advanced laparoscopic operations can be performed in patients who have previously undergone laparoscopic gastric bypass, because there are fewer adhesions than after open procedures. Also, revisions of previous laparoscopic gastric bypasses can be done laparoscopically for the same reasons. To demonstrate this, we present a patient who had undergone a laparoscopic gastric bypass. The operation was successful initially. After 10 months, she started to regain some of her lost weight. It was also found that she had developed idiopathic thrombocytopenia purpura, which was unresponsive to steroids. She underwent a splenectomy and revision of her gastric bypass, both done laparoscopically. This case demonstrates that these advanced laparoscopic procedures can be performed safely, even after previous surgery.     

脾次全切除腹膜后移位加断流术对门静脉高压性胃病的影响

目的　探讨脾次全切除腹膜后移位加断流术对门静脉高压性胃病 (PHG)的影响。方法　采用脾次全切除腹膜后移位加断流术治疗肝硬化门静脉高压症并上消化道出血 48例 ,47例获随访 2～ 12年 ,平均 91个月。通过胃镜、血管造影、彩色多普勒检查观察PHG及脾组织和脾血流的变化。结果　术后 2个月PHG分度比术前加重 (P <0 .0 5 ) ;术后 2年比术前改善 (P <0 .0 5 ) ,而比术后 2个月显著改善 ( P <0 .0 1) ;术后 5年与术前相比无明显变化 ( P >0 .0 5 )。远期再出血率为 5 .6%。结论　脾次全切除腹膜后移位加断流术对PHG有治疗作用。     

Pseudo-Gaucher cells in Hb E disease and thalassemia intermedia

Abstract

Pseudo-Gaucher cells are morphologic curiosities described in a number of conditions. We report their presence in a bone marrow biopsy and a spleen from 2 patients with hemoglobin E disease and thalassemia intermedia, respectively. The pathogenesis of these cells and their multiple known associations are discussed.     

内镜套扎联合脾切除治疗门静脉高压症的初步报告

目的 探讨内镜套扎(EVL)与脾切除联合治疗门静脉高压症食管静脉曲张的临床价值。方法 分别对18例急性出血者及14例非急性出血者采用EvL与脾切除联合治疗，并于术后3，6，12个月复查胃镜。如发现曲张静脉复发者，再行EVL。结果 31例术后随访≥2年，食管静脉曲张复发率6．4％(2／31)，未发现复发性出血患者，无肝性脑病及其它并发症死亡。结论 EVL与脾切除手术联合治疗门静脉高压症创伤小，并发症少，食管曲张静脉消除率高，对治疗和预防食管静脉曲张、破裂出血有较大的临床价值。     

腹腔镜加小切口脾切除治疗原发性血小板减少性紫癜:附13例报告

目的　探讨腹腔镜加小切口行脾切除术治疗原发性血小板减少性紫癜 (ITP )的效果。方法　笔者采用腹腔镜加小切口辅助对 13例ITP患者进行脾切除手术。即用腹腔镜游离脾脏后 ,于左肋缘下作一小切口 ,直视下结扎脾蒂 ,切除和取出脾脏。分析手术前后患者的血小板计数、并发症率及术后恢复情况。结果　 13例术后均未发生并发症 ;ITP治疗有效率为 10 0 %。结论　腹腔镜加小切口脾切除术治疗ITP是一种安全有效的手术方法     

腹腔镜辅助小切口行脾切除术治疗血液系统疾病

目的 探讨腹腔镜辅助小切口脾切除治疗血液系统疾病的可行性及效果。方法 应用腹腔镜游离脾周围韧带，辅加小切口处理脾蒂行脾切除，治疗经内科治疗无效的原发性血小板减少性紫癜(ITP)患者l6例，遗传性球形红细胞增多症患者(HS)4例。结果 本组20例均顺利完成手术，手术时间1．5～2．5h，平均2．2h。术中出血30～85ml，平均65ml。无脾窝积液或术中大出血，无切口感染、无手术死亡。住院天数4～7d，平均6d。术后随访0．5～25年，平均1．5年，无复发病例。结论 经腹腔镜辅助小切口脾切除对部分血液系统疾病的治疗具有微创、安全、有效、恢复快等优点，值得推广应用。     

Splenectomy in haematology–A 5-year single centre experience

Objective: To define indications and outcome in haematologic cases undergoing splenectomy.

Study design: A retrospective review of clinical records from consecutive patients having open or laparoscopic removal of the spleen in an academic centre in the private sector. Endpoints were survival, operating time, spleen size, histopathology, requirements for blood or related products complications and average costs.

Results: In the total group (n = 69) there were two deaths. Referrals were for immune thrombocytopaenia (41%), acquired haemolytic anaemia (10%), myeloproliferative syndrome (9%), acute or chronic leukaemia (19%), lymphoma (13%) and a miscellaneous group (8%), comprising cholelithiasis, aplasia or as a diagnostic procedure for otherwise unexplained splenomegaly. An open midline approach was predicated by spleens greater than twice normal size and a history of any bleeding disorder. Here the mean operating time was 83 min (range 40–295) whereas for laparoscopy this was 251 min (range 181–272).

Summary: Careful stratification between the two options facilitated optimum haemostasis and consequently reduced requirement for packed red cells and platelets. Neither underlying pathology nor the choice of treatment influenced morbidity or mortality. Overall local experience is consistent with published international standards of surgical practice. Outcome is directly proportional to the number of each procedure carried out by a single team, observance of consistent protocols for preoperative evaluation and standardized proactive management through the recovery period.     

腹腔镜脾切除治疗特发性血小板减少性紫癜的疗效观察

目的 探讨腹腔镜脾切除术治疗特发性血小板减少性紫癜(ITP)的手术安全性及临床疗效。方法 对21例ITP患者行腹腔镜切脾的临床资料进行回顾性分析。结果 21例ITP术后1周内血小板很快上升,术中失血少,全组均于术后24h内恢复胃肠蠕动,术后6h下床活动,平均住院时间4d。发生并发症4例,1例中转开腹,1例因术中渗血行腹腔镜下再次止血,1例膈下感染,1例皮下气肿。其中16例得到随访,2例复发。结论 腹腔镜脾切除术治疗ITP是安全可行的,且临床疗效显著。     

在基层施行脾切除治疗晚血286例的分析

本文报道晚血脾切除术286例。探讨了手术方法,脾血回收和并发症。实践证明:脾切除不仅能纠正脾功能亢进,而且可减少门静脉血流量,降低门静脉压力,同时手术死亡率较低(0.7%)可视为晚血的重要治疗方法之一。随访表明约80%以上的病人体质恢复,劳动增强;但上消化道出血和肝昏迷仍有发生,尚待进一步研究解决。