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协和医院外科(中译英)

大多数脾血管瘤患者无明显症状,本组患者中仅1例有左上腹痛症状。随着超声、CT、MRI等影像学技术的进步,脾血管瘤的检出者越来越多。由于血管瘤可发生梗塞、感染、纤维化、钙化等继发病变且可出现自发性破裂出血等严重并发症,所以一旦发现,均主张手术切除,可以行脾切除术或脾部分切除术。由于对脾脏具有一定的免疫等功能且脾全切后易发生凶险性感染的认识加深,近年来越来越强调争取行脾部分切除术。有学者提出脾部分切除术的适应证[5]:①年龄在60岁以下;②外伤性脾破裂为Ⅱ、Ⅲ级;③脾脏良性病变(脾脏血管瘤、动脉瘤、动静脉畸形)。其包括规则性脾切除术和非规则性脾切除术。前者先按血管分布,处理血管后,再行相应的脾段、叶或半脾切除术。后者是根据脾组织的血供及活力情况行非规则脾切除。目前对于单发的良性肿瘤且较小,位于上、下极或局限于某段或位于脾边缘,尤其是年轻人,可考虑节段性脾切除术,这样可以尽可能保留脾脏功能,降低脾切除术后凶险性感染[6]。本组病例平均年龄39.4岁,对脾功能要求较高,在随访过程中均未发现爆发性感染、血栓事件、脾坏死等并发症,证明很好地保留了脾脏功能。
随着腹腔镜等微创技术的进步,腹腔镜下脾部分切除术逐渐在临床中得到运用,特别是用于治疗遗传性球形红细胞增多症(hereditary spherocytosis)[7],对于其他囊性或者实性肿瘤的切除也偶有文献报道[8]。总结了上述文献后,我院近些年逐渐选择合适病例开展此术式。相比开腹脾部分切除术,腹腔镜具有创伤小、显露清楚、术后恢复快等显著优点,但是对术者要求比较高,需具备相当熟练的上腹部腔镜手术经验,对脾门部血管解剖非常熟悉。同时也并非所有脾肿瘤均适合,一般选择位于脾边缘或者上、下极,外突性生长最好。如果肿瘤巨大,导致空间有限,而且肿瘤取出困难,则不强求行腔镜手术。另外,如果脾脏周围粘连重,界限不清,术中容易出现大出血,可先行分离出脾动脉,进行临时阻断。如果分离困难,应及时中转开腹,不能单纯追求切口的“微创”而导致大量出血等内在大创伤。

Most patients with splenic hemangioma present no obvious symptoms, only one of the patients in the study presented with upper left abdominal pain. With advances in imaging techniques such as ultrasound, CT and MRI, more and more patients with splenic hemangioma are detected. Hemangioma, due to secondary infarction, infection, fibrosis, calcification and its serious complications such as spontaneous rupture and bleeding, is proposed to be resected by splenectomy or partial splenectomy once detected. With the deepening of knowledge on the immunological function of the spleen and overwhelming infection after a complete resection of the spleen, more and more emphasis is placed on the performance of partial splenectomy. Some scholars have presented the indications of partial splenectomy [5]: ① under the age of 60; ②II, III grade traumatic rupture; ③ benign diseases of the spleen (splenic hemangioma, aneurysm, arteriovenous malformation). Partial splenectomy includes regular splenectomy (in which the vessels are severed on the basis of the vascular distribution before the resection of the corresponding splenic segment, lobe or half the spleen) and irregular splenectomy (in which an irregular splenic resection is performed according to the blood supply and vitality of the spleen tissues). Segmental splenectomy is considered to be performed especially on the young people when the single benign tumor is small in size and located in the upper or lower pole or limited within a certain segment or at the edge of the spleen. Therefore, the splenic function can be preserved as much as possible and the occurrence of overwhelming infection after splenectomy can be lowered[6]. The splenic function should be better preserved for the mean age of the patients in the study is 39.4. No complications (overwhelming infection, thrombotic events and spleen necrosis) occurred during the follow up, which demonstrated the function of the spleen was well preserved.
With the advances in minimally invasive techniques such as laparoscope, laparoscopic partial splenectomy has gradually been applied in the clinical especially for the treatment of hereditary spherocytosis[7]. The resection of other cystic or solid tumors was also occasionally reported in the literature[8]. After the review of the literature, our hospital has gradually performed the surgical procedure for appropriate patients.Laparoscopy,with the significant advantages of less trauma, clear exposure and quick postoperative recovery in contrast to the open partial splenectomy, sets high requirements for surgeons who should have quite skilled experience in upper abdominal laparoscopic surgery and be quite familiar with the anatomy of the splenic hilar vessels. Laparoscopy, not suitable for all the spleen tumors though, is especially performed on the tumors in exogenous growth at the edge of the spleen or in the upper or lower pole of the spleen. A laparoscopic surgery is not necessary to be performed if the tumor is huge resulting in limited space and hard to be exteriorized. In addition, Intraoperative massive haemorrhage is prone to occur if there is much adhesion between the spleen and the neighboring organs with unclear boundary. So the splenic artery should be severed and temporarily occluded. If the dissection is difficult,the laparotomy should be performed without delay, the pursuit of the minimally invasive incision would result in inner large trauma such as massive haemorrhage, which should not be encouraged.

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