| Background and aimsPortal hypertension is a syndrome caused by abnormal hemodynamics and persistent increased pressure in portal vein,most of it caused by liver cirrhosis, mainly as splenomegaly, hypersplenism, portal communicans phlebectasia, ascites, etc, and upper gastrointestinal bleeding caused by portal communicans phlebectasia is one of the main cause of the death of end-stage liver disease.The surgery of portal hypertension has undergone many stages of change,shunt and devascularization as the two basic surgical procedures are now more mature.However,these two procedures only solve the variceal bleeding,the primary disease of liver is unable be improved.The emphasis of surgery of portal hypertension is not only to solve bleeding and hypersplenism,but also should strive to achieve a relative improvement in liver function. An ideal surgical approach should not only lowering the pressure in the portal system,but also to ensure adequate blood perfusion to the liver. A primary consensus has been reached currently in medical circle,though both shunt and devascularization are unable to fully meet the requirements above, devascularization is relatively more reasonable.Great changes of the liver hemodynamics occurred in patients pre- and post- devascularization, such as hepatic artery flow, portal vein flow and free portal venous pressure,changes of all these factors affect on liver function.The study of liver metergasis and its relationship with liver hemodynamics in patients with cirrhosis and portal hypertension pre- and post- devascularization has very important clinical significance.MethodsA retrospective analysis of clinical data was made in 52 cases of portal hypertension caused by liver cirrhosis admitted for operation in department of hepatobiliary from June 2008 to December 2010.The clinical data include age, gender, basic liver disease, past history, bleeding history, physical examination, endoscopy ,also include retention rate of indocyanine green 15-minutes,model for end-stage liver disease score,hepatic artery flow, portal vein flow of preoperation and later 2,4,8,12 weeks after esophagogastric devascularization combined with splenectomy,as well as the free portal venous pressure pre- and post- Splenectomy and post-devascularization.To compare the variation and discuss the relationship of these data.Results1. Retention rate of indocyanine green 15-minutes: Data of preoperation and later 2,4 weeks after operation was 25.9±10.5%,25.6±10.2%,25.4±10.1% respectively.There were no statistical significance(P>0.05) between each time; data of later 8,12 weeks after operation was 22.0±8.6%,18.8±8.3% respectively, it showed the statistical significance (P<0.05) between each time and the former .2. Model for end-stage liver disease score: Data of preoperation and later 2 weeks after operation was 18.5±5.2,17.8±4.5 respectively,and there was no statistical significance(P>0.05) between two times; data of later 4,8,12 weeks after operation was 16.0±3.9,15.0±3.9,13.8±3.2 respectively,it showed the statistical significance(P<0.05) between each time and the former.3. Hepatic artery flow: Data of preoperation and later 2, 4, 8 weeks after operation was 374.1±86.1ml/min,526.7±135.0ml/min,535.8±139.2ml/min,539.6±140.3ml/min respectively,it showed the statistical significance(P<0.05) between the later three times and each former; data of later 12 weeks after operation was 540.1±140.3ml/min,and there was no statistical significance(P>0.05) between it and the former.4. Portal vein flow: Data of preoperation and later 2, 4, 8 week after operation was 1427.8±312.4ml/min,1117.5±213.7ml/min,1165.6±219.3ml/min,1188.6±225.5ml/min respectively, it showed the statistical significance(P<0.05) between the later three times and each former;data of later 12 weeks after operation was 1192.3±224.2ml/min,and there was no statistical significance(P>0.05) between it and the former.5. Free portal venous pressure: Data of pre- and post- splenectomy and post- devascularization was 36.3±5.8cmH2O,29.2±5.8 cmH2O,30.8±5.5cmH2O respectively, there are statistical significance(P<0.05) between each time.6. Correlation: (1) Excluding the influence of portal vein flow: variation of retention rate of indocyanine green 15-minutes between preoperation and later 8 weeks after operationshowed negative correlation with variation of hepatic artery flow during the same period(r= - 0.699); variation of model for end-stage liver disease score between preoperation and later 4 weeks after operation showed negative correlation with variation of hepatic artery flow during the same period(r=-0.670). (2) Excluding the influence of hepatic artery flow: variation of retention rate of indocyanine green 15-minutes between preoperation and later 8 weeks after operation showed positive correlation with variation of portal vein flow during the same period(r=0.592); variation of model for end-stage liver disease score between preoperation and later 4 weeks after operation showed positive correlation with variation of portal vein flow during the same period (r=0.677). (3)Excluding the influence of hepatic artery flow: variation of retention rate of indocyanine green 15-minutes between preopreation and later 8 weeks after operation showed positive correlation with variation of free portal venous pressure between pre- and post- splenectomy(r=0.324); variation of model for end-stage liver disease score between preoperation and later 4 week after operation showed positive correlation with variation of free portal venous pressure between post-splenectomy and pre-devascularization(r= 0.358).Conclusion1. Liver function can be restored during 1 month after surgery and gradually improved subsequently,the recovery of liver functional reserve started after 4 weeks post-devascularization,the allomeric function of liver recovered earliler than the Reserve function.2. Esophagogastric devascularization combined with splenectomy can decrease free portal venous pressure moderately,and strengthen the perfusion of hepatic artery flow on liver.3. Liver function and liver functional reserve can be improved by the strength of perfusion of hepatic artery flow on liver. Liver function has negative correlationwith portal vein flow based on the premise that portal vein perfusion can be maintained in a certain level. Liver function can be improved if free portal venous pressure decreased moderately; the improvement of liver function attribute to the correlative variation of hepatic artery flow and portal vein flow.4. Skeletonized disconnection and intramural disconnection is an ideal procedure in curing liver cirrhosis and portal hypertension,it play an im portant role on improving long-term postoperative liver function. |
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