比较内镜治疗、中心性脾静脉-肾静脉分流术或脾静脉-腔静脉分流术和门静脉-奇静脉断流术3种方法治疗肝硬化门脉高压症患者食管静脉曲张套扎术后复发再出血的临床疗效。

本前瞻性研究对象为2005年3月至2011年3月中南大学湘雅三医院普外科收治的肝硬化门静脉高压症食管静脉曲张套扎术后复发再出血患者190例。所有患者均签署知情同意书，符合医学伦理学规定。采用随机数字表法将患者随机分为内镜治疗组（72例）、分流术组（56例）和断流术组（62例）3组。内镜治疗组患者继续采用以内镜套扎术为主的综合治疗。分流术组患者采用中心性脾静脉-肾静脉分流术（切除脾，将脾静脉近端与左肾静脉端侧吻合）或脾静脉-腔静脉分流术，血管吻合口直径大小限定为10 mm。断流术组患者采用脾切除加门静脉-奇静脉断流术。术后观察3组患者的近期疗效和并发症，并进行定期复查、随访。各组门静脉压力变化、总住院时间及住院费用比较采用t检验，并发症及随访观察指标比较采用χ²检验。

3组患者经治疗后均成功止血，内镜治疗组有1例（1%）患者套扎后6 d大出血，经三腔二囊管压迫及药物治疗后缓解。断流术组和分流术组治疗后的门静脉压力均较治疗前明显降低（t=17.47、25.71，均为P<0.05）；与断流术组比较，分流术组治疗后的门静脉压力更低（t=12.20，P<0.05）。断流术组围手术期门静脉血栓形成率明显高于分流术组（χ²=4.62，P<0.05）。分流术组的复发出血率、食管静脉曲张复发率、门脉高压性胃病发生率、肝性脑病发生率均低于内镜治疗组和断流术组，且总住院时间和总住院费用亦低于内镜治疗组和断流术组（均为P<0.05）。

对肝硬化食管静脉曲张内镜套扎术后复发再出血患者，中心性脾静脉-肾静脉分流术或脾静脉-腔静脉分流术的临床效果优于门静脉-奇静脉断流术和内镜治疗。

To compare the effects of endoscopic variceal ligation(EVL), central splenorenal or splenocaval shunt and port-azygos devascularization in treating the recurrent hemorrhage for hepatocirrhosis portal hypertension with esophageal varice after EVL.

Clinical data were collected from 190 patients with recurrence of bleeding after EVL for hepatocirrhosis portal hypertension with esophageal varice in the Third Xiangya Hospital of Central South University from March 2005 to March 2011. Local ethical committee approval had been received and that the informed consent of all participating subjects was obstained. All patients were randomly assigned to three treatment groups: endoscopic treatment group (n= 72), splenorenal/splenocaval shunt group(n=56) and devascularization group (n=62). Patients in the endoscopic treatment group continued to received EVL treatment. In the shunt group, the patients underwent spleen resection plus splenorenal/splenocaval shunt, in which anastomosis of near-end of splenic vein to end-to-side of left renal or splenocaval shunt was performed with the diameter of stoma less than 10 mm. Spleen resection plus port-azygos devascularization were applied in the devascularization group. Short term effect and complications of 3 groups were observed after operation and postoperative follow-up examinations were performed. The t test was applied to compare the differences of portal pressure changes, the total hospitalization time and costs of 3 groups. The chi-square test was applied to compare the differences of complications and follow-up observations.

All patients in the 3 groups stopped bleeding after treatment. One patient (1%) in the endoscopic treatment group developed massive hemorrhage after 6 days after EVL and the hemorrhage was relieved after inserting sengstaken-blakemore tube and medicine treatment. The portal pressure in the splenorenal/splenocaval shunt group and devascularization group were reduced obviously (t=17.47, 25.71, P<0.05, P<0.05); The portal pressure in the splenorenal/splenocaval shunt group was lower than that in devascularization group(t=12.20, P<0.05). The incidence of perioperative portal vein thrombosis was higher in deavascularization group compared with splenorenal/splenocaval shunt group(χ²=4.62, P<0.05). The rates of rebleeding, recurrance of esophageal varice, portal hypertensive gastropathy (PHG) and hepatic encephalopathy in splenorenal/splenocaval shunt group were lower compared with the endoscopic treatment and devascularization group. The total hospitalization time and costs in splenorenal/splenocaval shunt group were also less than those in endoscopic treatment and devascularization groups(P<0.05).

Compared with endoscopic treatment and port-azygos devascularization, splenorenal or splenocaval shunt demonstrates better effect in treating hepatocirrhosis portal hypertension with esophageal varice rebleeding after endoscopic variceal ligation.