肝硬化脾亢脾切除术后门静脉血栓形成影响因素

doi:10.3877/cma.j.issn.2095-3232.2024.01.008

目的

探讨肝硬化脾功能亢进症（脾亢）脾切除术后门静脉血栓形成（PVT）的危险因素。

方法

回顾性分析2016年7月至2019年4月于中山大学附属第三医院行脾切除术的136例肝硬化脾亢患者临床资料。其中男101例，女35例；平均年龄为（48±11）岁。病毒性肝炎113例，肝豆状核变性8例。患者均签署知情同意书，符合医学伦理学规定。根据术后有无发生PVT，将患者分为PVT组（77例）和非PVT组（59例）。收集患者围手术期临床相关指标，采用单因素和Logistic多因素回归分析PVT形成的危险因素，ROC曲线分析危险因素诊断最佳界值。

结果

肝硬化脾亢脾切除术后PVT发生率57%（77/136），75%（58/136）的PVT发生在术后10 d内。单因素分析显示，内镜治疗史、术前凝血酶时间（TT）、脾脏长径、脾肋间厚径、门静脉内径、术前脾静脉内径和术后门静脉内径、手术当天及术后5～6 d RBC、手术当天Plt、术后2～4 d TT与术后PVT发生有关（P<0.05）。Logistic多因素分析显示，内镜治疗史、手术当天Plt、术后门静脉内径是术后PVT发生的独立影响因素（OR=3.556，1.020，1.449；P<0.05）。ROC曲线分析显示，手术当天Plt>62×10⁹/L诊断术后PVT的敏感度0.597，特异度0.593；术后门静脉内径>13.5 mm诊断术后PVT的敏感度0.390，特异度0.864。

结论

肝硬化脾亢脾切除术后PVT发生率较高，术后门静脉内径>13.5 mm、术后当天Plt>62×10⁹/L及内镜治疗史是肝硬化脾亢脾切除术后发生PVT的独立危险因素。

关键词: 门静脉血栓, 肝硬化, 脾切除术, 脾功能亢进, 危险因素, 门静脉内径, 血小板

Objective

To investigate the risk factors of portal vein thrombosis (PVT) after splenectomy in patients with cirrhotic hyperplenism.

Methods

Clinical data of 136 cirrhosis patients complicated with hypersplenism who underwent splenectomy in the Third Affiliated Hospital of Sun Yat-senUniversity from July 2016 to April 2019 were retrospectively analyzed. Among them, 101 patients were male and 35 female, aged (48±11) years on average. 113 cases were diagnosed with viral hepatitis and 8 cases of hepatolenticular degeneration. The informed consents of all patients were obtained and the local ethical committee approval was received. According to postoperative incidence of PVT, all patients were divided into the PVT (n=77) and non-PVT groups (n=59). Clinical indexes were collected during perioperative period. The risk factors of PVT were analyzed by univariate and multivariate Logistic regression analyses, and the optimal diagnostic threshold values of risk factors were analyzed by the ROC curve.

Results

The incidence of PVT was 57%(77/136) after splenectomy in patients with cirrhotic hyperplenism, and 75%(58/136) occurred within 10 d after splenectomy. Univariate analysis showed that endoscopic treatment history, preoperative thrombin time (TT), splenic maximum diameter, splenic intercostal thickness, portal vein diameter, preoperative splenic vein diameter and postoperative portal vein diameter, RBC on the day of surgery and 5-6 d after surgery, Plt on the day of surgery, and TT on 2-4 d after surgery were correlated with the incidence of postoperative PVT (P<0.05). Multivariate Logistic analysis showed that endoscopic treatment history, Plt on the day of surgery, and portal vein diameter were the independent factors influencing the incidence of postoperative PVT (OR=3.556, 1.020, 1.449; P<0.05). ROC curve revealed that the sensitivity and specificity of Plt>62×10⁹/L on the day of surgery in the diagnosis of postoperative PVT were 0.597 and 0.593. The sensitivity and specificity of postoperative portal vein diameter>13.5 mm in the diagnosis of postoperative PVT were 0.390 and 0.864.

Conclusions

The incidence of PVT after splenectomy in patients with cirrhotic hyperplenism is relatively high. Postoperative portal vein diameter>13.5 mm, Plt>62×10⁹/L on the day of surgery and endoscopic treatment history are the independent risk factors for PVT after splenectomy.

Key words: Portal vein thrombosis, Liver cirrhosis, Splenectomy, Hypersplenism, Risk factors, Diameter of portal vein, Platelet

表1 肝硬化脾亢脾切除患者术后PVT的单因素分析

因素	PVT组	非PVT组	统计值	P值
内镜治疗史（例）	44	15	χ²=13.68	<0.001
术前TT [s，M（Q₁，Q₃）]	17.3（16.5，17.8）	17.6（17.2，18.4）	Z=-2.50	0.012
脾脏长径[mm，M（Q₁，Q₃）]	178（163，201）	172（156，180）	Z=2.34	0.019
脾肋间厚径[mm，M（Q₁，Q₃）]	63（55，71）	59（53，64）	Z=2.42	0.016
术前门静脉内径[mm，M（Q₁，Q₃）]	14（13，16）	13（10，14）	Z=3.31	0.001
术前脾静脉内径[mm，M（Q₁，Q₃）]	12（10，14）	11（9，12）	Z=2.58	0.009
术后门静脉内径（mm，±s）	13.3±2.5	12.1±1.5	t=3.20	0.002
手术当天RBC（×10¹²/L，±s）	4.1±0.8	3.8±0.8	t=-2.31	0.022
手术当天Plt [×10⁹/L，M（Q₁，Q₃）]	66（49，87）	57（42，71）	Z=2.27	0.023
术后第5～6 d RBC（×10¹²/L，±s）	3.7±0.9	3.5±0.8	t=2.33	0.021
术后第2～4 d TT [s，M（Q₁，Q₃）]	14.9（14.3，15.8）	15.5（14.9，16.2）	Z=-2.88	0.004

表1 肝硬化脾亢脾切除患者术后PVT的单因素分析

因素	PVT组	非PVT组	统计值	P值
内镜治疗史（例）	44	15	χ²=13.68	<0.001
术前TT [s，M（Q₁，Q₃）]	17.3（16.5，17.8）	17.6（17.2，18.4）	Z=-2.50	0.012
脾脏长径[mm，M（Q₁，Q₃）]	178（163，201）	172（156，180）	Z=2.34	0.019
脾肋间厚径[mm，M（Q₁，Q₃）]	63（55，71）	59（53，64）	Z=2.42	0.016
术前门静脉内径[mm，M（Q₁，Q₃）]	14（13，16）	13（10，14）	Z=3.31	0.001
术前脾静脉内径[mm，M（Q₁，Q₃）]	12（10，14）	11（9，12）	Z=2.58	0.009
术后门静脉内径（mm，±s）	13.3±2.5	12.1±1.5	t=3.20	0.002
手术当天RBC（×10¹²/L，±s）	4.1±0.8	3.8±0.8	t=-2.31	0.022
手术当天Plt [×10⁹/L，M（Q₁，Q₃）]	66（49，87）	57（42，71）	Z=2.27	0.023
术后第5～6 d RBC（×10¹²/L，±s）	3.7±0.9	3.5±0.8	t=2.33	0.021
术后第2～4 d TT [s，M（Q₁，Q₃）]	14.9（14.3，15.8）	15.5（14.9，16.2）	Z=-2.88	0.004

表2 肝硬化脾亢脾切除患者术后PVT的Logistic多因素回归分析

变量	b	SE（b）	Wald χ²	OR	95%CI	P
内镜治疗史	1.271	0.401	9.998	3.556	1.621～7.843	0.001
手术当天Plt	0.200	0.008	5.783	1.020	1.004～1.037	0.016
术后门静脉内径	0.371	0.115	10.329	1.449	1.156～1.816	0.002

表2 肝硬化脾亢脾切除患者术后PVT的Logistic多因素回归分析

变量	b	SE（b）	Wald χ²	OR	95%CI	P
内镜治疗史	1.271	0.401	9.998	3.556	1.621～7.843	0.001
手术当天Plt	0.200	0.008	5.783	1.020	1.004～1.037	0.016
术后门静脉内径	0.371	0.115	10.329	1.449	1.156～1.816	0.002

图1 手术当天Plt及术后门静脉内径预测术后PVT的ROC曲线注：PVT为门静脉血栓形成

表3 手术当天Plt及术后门静脉内径预测肝硬化脾切除术后PVT的诊断效能

危险因素	AUC	P	95%CI	最佳界值
手术当天Plt	0.614	0.023	0.519～0.708	62×10⁹/L
术后门静脉内径	0.653	0.002	0.561～0.744	13.5 mm

表3 手术当天Plt及术后门静脉内径预测肝硬化脾切除术后PVT的诊断效能

危险因素	AUC	P	95%CI	最佳界值
手术当天Plt	0.614	0.023	0.519～0.708	62×10⁹/L
术后门静脉内径	0.653	0.002	0.561～0.744	13.5 mm

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Influencing factors of portal vein thrombosis after splenectomy in patients with cirrhotic hyperplenism

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Influencing factors of portal vein thrombosis after splenectomy in patients with cirrhotic hyperplenism