本文選題：肝硬化 + 脾功能亢進�。� 參考：《昆明醫(yī)科大學》2015年碩士論文

【摘要】：背景脾功能亢進(脾亢)是肝硬化門脈高壓癥患者最常見的并發(fā)癥之一,而脾臟是一個有多種重要功能的器官,傳統(tǒng)的脾切除術存在著較大的局限性和并發(fā)癥。已逐漸被部分脾動脈栓塞術(Partial splenic artery embolization, PSE)所取代,但PSE也仍然存在著栓塞后綜合征、脾膿腫等不良反應及并發(fā)癥。隨著介入放射學的發(fā)展,近些年,采用射頻消融術(Radiofrequency ablation, RFA)治療脾亢的報道日益增多,為脾亢治療開辟了新的途徑,RFA可引起組織的凝固性壞死,而非液化性壞死,通常認為RFA術后脾膿腫、感染的發(fā)生率較低,并發(fā)癥較少,安全性較高,但同時也有對RFA治療脾亢持懷疑態(tài)度的,他們認為RFA具有治療范圍難以精確的本身技術缺陷,遠期療效不明,且術中不良反應多,容易導致腹腔大出血的風險。究竟兩種方法在治療肝硬化門脈高壓性脾亢中應用的各自療效及優(yōu)勢如何值得進一步的探討。目的對PSE與RFA兩種方法在治療肝硬化門脈高壓性脾亢中的療效、不良反應及并發(fā)癥進行對比分析,探索一種療效確切、安全性高、并發(fā)癥少的治療方案,從而為患者選擇合適的治療方案提供依據(jù)。資料與方法經(jīng)醫(yī)院倫理委員會批準,對我院連續(xù)收治的2012年08月至2014年04月間符合入組標準的60例肝硬化門靜脈高壓脾功能亢進患者在術前簽署知情同意書后進行隨機分組,將患者分為部分脾動脈栓塞組(對照組)和射頻消融組(研究組)。分別于術前、術后1周、2周、1個月、3個月、6個月、12個月行血常規(guī)、腹部CT檢查,記錄手術時間、術中、術后不良反應,住院時間及住院費用情況,對各項指標進行統(tǒng)計分析,對組間差異進行對比,分析、探討相關影響因素。結果(1)PSE組平均手術時間為(1.2±0.5)h, RFA組平均手術時間為(3.8±1.1) h, RFA組手術時間明顯高于PSE組(P0.05)。(2)PSE組術中VAS疼痛評分平均為(1.2±0.9)分,RFA組術中VAS疼痛評分平均為(5.3±1.41)分,RFA組術中疼痛評分明顯高于PSE組(P0.05)。(3)PSE組術后不良反應評價指標較RFA組顯著增高(P0.05)。(4)PSE組脾臟壞死比例為40%-80%,平均為(62.2±10.1)%,術后1周、2周、1個月、3個月、6個月、12個月外周血細胞計數(shù)分別較術前顯著改善,差異有統(tǒng)計學意義(P0.05),其中2例脾臟壞死比例在50%以下的患者術后12個月外周血細胞計數(shù)降至術前水平；RFA組脾臟壞死比例為20%-60%,平均為(30.7±10.2)%,術后1周、2周、1個月、3個月外周血細胞計數(shù)分別分別較術前改善,差異有統(tǒng)計學意義(P0.05),術后6個月外周血細胞計數(shù)明顯下降(P0.05),脾功能亢進復發(fā),1年后外周血細胞計數(shù)降至術前水平,其中9例脾臟壞死比例在50%-60%的患者術后12個月外周血細胞計數(shù)仍維持在較高水平；兩組中PSE組術后血小板及白細胞計數(shù)改善明顯優(yōu)于RFA組(P0.05)。(5)PSE組住院時間為15-100天,平均為(22.3±3.7)天,RFA組住院時間為10-30天,平均為(16.8±5.2),PSE組住院時間高于RFA組(P0.05)。(6)PSE組平均住院費用為26212.71±31093.12元,RFA組平均住院費用為27391.23±19375.67元,兩組間統(tǒng)計學無差異。結論1、PSE與RFA兩種方法對脾功能亢進者均療效確切,兩種方法術后療效與脾臟壞死比例均呈正相關性。2、PSE與RFA兩種方法術后不良反應及并發(fā)癥與脾臟壞死比例均呈正相關性。PSE術中手術時間短,不良反應較輕,術中嚴格控制脾臟的栓塞比例,可顯著減輕術后不良反應及并發(fā)癥的發(fā)生率,RFA受制于器械、材料等原因,單針消融范圍不足,術中為了擴大消融范圍,從而導致患者手術時間增長、疼痛增加,不良反應加重.本研究認為現(xiàn)階段我們傾向于優(yōu)選PSE治療方法。
[Abstract]:Hypersplenism (hypersplenism) is one of the most common complications in patients with cirrhosis of the portal hypertension, and the spleen is an organ with many important functions. Traditional splenectomy has great limitations and complications. It has been gradually replaced by Partial splenic artery embolization (PSE), but PSE also There still exist adverse reactions and complications of post embolic syndrome and splenic abscess. With the development of interventional radiology, the treatment of hypersplenism with Radiofrequency ablation (RFA) has increased in recent years, which has opened a new way for the treatment of hypersplenism. RFA can cause coagulation necrosis of tissue, not liquefied necrosis. It is believed that the incidence of splenic abscess after RFA is low, the complications are less and the safety is higher, but at the same time, it also has a skeptical attitude to the treatment of hypersplenism with RFA. They think that RFA has the difficulty of the precise technical defects in the treatment range, the long term effect is unknown, and the adverse reaction is easy to lead to the risk of massive hemorrhage in the abdominal cavity. Two kinds of methods are used. The efficacy and advantages of the method in the treatment of Hepatocirrhosis Portal Hypertensive hypersplenism are worthy of further discussion. Objective to compare the efficacy, adverse reactions and complications of the two methods of PSE and RFA in the treatment of hepatocirrhosis with hyperbaric hypersplenism, and to explore a therapeutic scheme with definite curative effect, high safety and less complications. According to the data and methods approved by the hospital ethics committee, 60 patients with cirrhosis of the portal hypertension and hypersplenism between 08 months and 04 months in our hospital from 2012 to 2014 were randomly divided into parts, and the patients were divided into parts. Splenic artery embolization group (control group) and radiofrequency ablation group (Study Group) were performed before operation, 1 weeks, 2 weeks, 1 months, 3 months, 6 months, 12 months of blood routine, abdominal CT examination, record the operation time, intraoperative, postoperative adverse reactions, hospitalization time and hospitalization expenses, the statistical analysis of the indexes, the differences of groups were compared and analyzed. Results (1) the average operation time of group PSE was (1.2 + 0.5) h, the average operation time of group RFA was (3.8 + 1.1) h, and the operation time of group RFA was significantly higher than that of group PSE (P0.05). (2) the average of VAS pain score in group PSE was (1.2 + 0.9), VAS pain score in RFA group was (5.3 + 1.41), and the pain score in RFA group was significantly higher than that in the group of RFA. Group PSE (P0.05). (3) the evaluation index of postoperative ADR in group PSE was significantly higher than that in group RFA (P0.05). (4) the proportion of spleen necrosis in group PSE was 40%-80%, average (62.2 + 10.1)%, 1 weeks, 2 weeks, 1 months, 3 months, 6 months, 12 months, 12 months, and 12 months, respectively, compared with before operation, and the difference was statistically significant (P0.05), of which 2 cases of splenic necrotic ratio were compared. The blood cell count of the patients under 50% months after operation was reduced to the preoperative level. The proportion of spleen necrosis in group RFA was 20%-60%, the average was (30.7 + 10.2)%, 1 weeks, 2 weeks, 1 months after operation, 1 months and 3 months, respectively. The difference was statistically significant (P0.05), and the number of peripheral blood cells decreased significantly in 6 months after the operation (P0 .05), the recurrence of hypersplenism, 1 years after the peripheral blood cell count decreased to the preoperative level, of which 9 cases of spleen necrosis in the patients with 50%-60% after 12 months of peripheral blood cell count still maintained at a high level; the two group of group PSE after the improvement of platelet and leukocyte count was significantly better than the RFA group (P0.05). (5) the PSE group was hospitalized for 15-100 days, The average time was (22.3 + 3.7) days, the time of hospitalization in group RFA was 10-30 days, the average was (16.8 + 5.2), and the time of hospitalization in group PSE was higher than that of group RFA (P0.05). (6) the average hospitalization cost in group PSE was 26212.71 + 31093.12 yuan, the average hospitalization cost in group RFA was 27391.23 + 19375.67 yuan, and there was no statistical difference between group two. Conclusion 1, PSE and RFA two methods were all treated with hypersplenism of spleen. The two methods had positive correlation with the proportion of spleen necrosis after the two methods, PSE and RFA had positive correlation with the two methods of postoperative adverse reactions and complications and the proportion of spleen necrosis. The operation time was shorter in.PSE operation, less adverse reaction, and the strict control of splenic embolization in the operation could significantly reduce the postoperative adverse reactions and complications. The incidence of RFA is controlled by instruments, materials, and other reasons. The single needle ablation range is insufficient. In order to expand the range of ablation, the operation time increases, the pain increases, and the adverse reaction is aggravated. This study suggests that we prefer to optimize the PSE treatment at this stage.
【學位授予單位】：昆明醫(yī)科大學
【學位級別】：碩士
【學位授予年份】：2015
【分類號】：R657.63

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