探讨利伐沙班在脾切除联合贲门周围血管离断术后门静脉血栓（PVT）治疗中的疗效。

回顾性分析2019年6月1日至2022年6月1日解放军总医院第五医学中心行脾切除联合贲门周围血管离断的37例肝硬化伴PVT患者临床资料。其中男10例，女27例；平均年龄（52±4）岁。患者均签署知情同意书，符合医学伦理学规定。其中乙型病毒性肝炎肝硬化27例，自身免疫性肝硬化8例，酒精性肝硬化2例。术前存在PVT合并消化道出血12例，单纯上消化道出血25例。37例患者术后第1～3 d应用低分子量肝素钙治疗，随后改为利伐沙班口服，根据用药反应及凝血酶原活动度，调整利伐沙班用量。术后3～5 d常规行彩超或上腹部增强CT检查，判断PVT变化；术后1个月复查增强CT评估临床效果。

术后1周复查显示新发PVT发生率38%（14/37），其中Ⅰ级8例，Ⅱ级3例，Ⅲ级2例，Ⅳ级1例。其中合并术前陈旧性PVT患者新发PVT发生率约58%（7/12），其中3例新发PVT完全溶解，3例新发PVT部分溶解，1例门静脉海绵样变，术后出现Ⅳ级PVT，经溶栓+经颈内静脉门静脉取栓均失败，继续口服利伐沙班。术前合并陈旧血栓者，血栓未见溶解考虑血栓机化；单纯上消化道出血患者PVT发生率28%（7/25），其中4例新发PVT完全溶解，其余3例新发PVT部分溶解。术后使用利伐沙班后牙龈及皮下出血6例，利伐沙班减量后出血停止。所有患者PVT溶解后继续口服利伐沙班6个月。

脾切除联合贲门周围血管离断术后应用利伐沙班预防术后新发门静脉血栓安全、有效，可使脾切除联合贲门周围血管离断术后患者获益。

To evaluate the efficacy of rivaroxaban in the treatment of portal vein thrombosis (PVT) after splenectomy combined with pericardial devascularization.

Clinical data of 37 patients with liver cirrhosis complicated with PVT who underwent splenectomy combined with pericardial devascularization in Fifth Medical Center of PLA General Hospital from June 1, 2019 to June 1, 2022 were retrospectively analyzed. Among them, 10 patients were male and 27 female, aged (52±4) years on average. The informed consents of all patients were obtained and the local ethical committee approval was received. Among them, 27 patients were diagnosed with hepatitis B virus cirrhosis, 8 cases of autoimmune cirrhosis and 2 cases of alcoholic cirrhosis. 12 cases were diagnosed with PVT complicated with gastrointestinal bleeding and 25 cases of upper gastrointestinal bleeding alone before surgery. 37 patients were treated with low-molecular-weight heparin at postoperative 1 to 3 d, and then changed to oral intake of rivaroxaban. The dosage of rivaroxaban was adjusted according to drug reactions and prothrombin activation. At postoperative 3-5 d, routine color Doppler ultrasound or enhanced CT scan of upper abdomen were performed to assess the changes of PVT. At postoperative 1 month, enhanced CT scan was performed to evaluate clinical efficacy.

At postoperative 1 week, the incidence of de novo PVT was 38%(14/37), including8 cases of grade Ⅰ, 3 cases of grade Ⅱ, 2 cases of grade Ⅲ and 1 case of grade Ⅳ. The incidence of de novo PVT in patients with old PVT before surgery was approximately 58% (7/12), including 3 cases of complete thrombolysis of de novo PVT, 3 cases of partial thrombolysis of de novo PVT, and 1 case of cavernous transformation of the portal vein who suffered grade Ⅳ PVT postoperatively. Thrombolysis combined with embolectomy through internal jugular vein yielded no efficacy, and oral intake of rivaroxaban was given. For patients with old PVT before surgery, PVT could not be treated, considering the possibility of thrombosis organization. The incidence of PVT in patients with upper gastrointestinal bleeding alone was 28% (7/25), including 4 cases of complete thrombolysis of de novo PVT and 3 cases of partial thrombolysis of de novo PVT. 6 patients developed gingival and subcutaneous bleeding after oral intake of rivaroxaban, which was alleviated after reducing the dosage of rivaroxaban. All patients were given with oral intake of rivaroxaban for 6 months after PVT thrombolysis.

Rivaroxaban after splenectomy combined with pericardial devascularization is safe and efficacious protocol in preventing de novo PVT, which can bring benefits to patients after splenectomy combined with pericardial devascularization.