脾切除术后发热.ppt

Peking University School of OncologyHPB Surgical Department脾切除术后发热脾切除术后发热(f r)Post-splenectomy Fever 刘茂兴第一页，共四十五页。Peking University School of OncologyHPB Surgical Department 术后发热(f r)机理病原菌免疫力免疫力发热发热第二页，共四十五页。Peking University School of OncologyHPB Surgical Department术后发热术后发热(f r)原因原因 术后体温(twn)低38 3天后将至正常超过38，持续不退,或者一度降至正常,又突然(trn)上升，一般在术后4-5天，达到39-40 以上非感染性感染性吸收热反应热 特点 特点第三页，共四十五页。Peking University School of OncologyHPB Surgical Department脾切除脾切除(qich)术后高热、感染的发生率术后高热、感染的发生率远超过胃大部切除远超过胃大部切除(qich)、单纯胆囊切、单纯胆囊切除除(qich)术术why第四页，共四十五页。Peking University School of OncologyHPB Surgical Department脾脏的解剖(jipu)生理生命(shngmng)阳光尊严第五页，共四十五页。Peking University School of OncologyHPB Surgical Department脾脏(pzng)的发生第六页，共四十五页。Peking University School of OncologyHPB Surgical Department脾的发生(fshng)第七页，共四十五页。Peking University School of OncologyHPB Surgical Department第八页，共四十五页。Peking University School of OncologyHPB Surgical Department第九页，共四十五页。Peking University School of OncologyHPB Surgical Department脾脏(pzng)的组织学结构白髓（白髓（White Pulp）由密集的淋巴细胞构成,是机体发生特异性免疫特异性免疫的主要场所。当抗原侵入脾引起体液免疫应答时,白髓内淋巴小结会大量增多红髓（红髓（Red Pulp）主要由脾血窦和脾索组成,红髓内血流缓慢,使抗原与吞噬细胞的充分接触成为可能,是免疫细胞(xbo)发生吞噬作用的主要场所。边缘区(marginal zone,MZ)位于红髓和白髓的交界处,此区淋巴细胞较白髓稀疏,以B 细胞为主,但有较多的巨噬细胞(MU),是脾内捕获抗原、识别抗原和诱发免疫应答的重要部位。第十页，共四十五页。Peking University School of OncologyHPB Surgical DepartmentWhite PulpRed PulpHistologic features of the Spleen第十一页，共四十五页。Peking University School of OncologyHPB Surgical DepartmentCordsSinusRed Pulp Histology第十二页，共四十五页。Peking University School of OncologyHPB Surgical DepartmentMantle zoneMarginal zoneGerminalcenter第十三页，共四十五页。Peking University School of OncologyHPB Surgical Department第十四页，共四十五页。Peking University School of OncologyHPB Surgical Department脾脏(pzng)功能一、一、脾脏免疫功能脾脏免疫功能二、二、脾脏的内分泌功能脾脏的内分泌功能三、脾脏与血友病甲三、脾脏与血友病甲四、四、脾脏与肝脏脾脏与肝脏(gnzng)的关系的关系五、五、脾脏与肠道脾脏与肠道六、血脾屏障六、血脾屏障第十五页，共四十五页。Peking University School of OncologyHPB Surgical Department脾脏免疫(miny)功能非特异性免疫非特异性免疫(miny)功能功能 吞噬作用（巨噬细胞）特异性免疫功能特异性免疫功能-细胞免疫（T淋巴细胞）体液免疫（B淋巴细胞）第十六页，共四十五页。Peking University School of OncologyHPB Surgical Department免疫功能(gngnng)组成 免疫细胞免疫细胞：T 细胞、B 细胞、K 细胞、巨噬单核细胞、自然杀伤细胞、杀伤细胞、淋巴因子活化(huhu)杀伤细胞(LAK 细胞)、树突状细胞。免疫因子免疫因子：tufstin 因子、备解素、纤维结合蛋白、免疫核糖核酸、环磷酸鸟苷、内源性细胞毒因子、调理素和补体。第十七页，共四十五页。Peking University School of OncologyHPB Surgical Department脾脏(pzng)的分泌功能 是一种作用很强的免疫调节因子亦可通过增强巨噬细胞、NK 细胞、粒细胞杀伤病原菌及肿瘤细胞的细胞毒作用。提高T 细胞依赖性抗体的水平(shupng),增强机体抗感染和肿瘤的体液免疫反应。tuftsin第十八页，共四十五页。Peking University School of OncologyHPB Surgical Department脾脏脾脏(pzng)与肠道与肠道正常情况下脾脏通过其自身拥有的丰富的免疫细胞及免疫因子对肠道发挥作用。Weber 等提出脾切除(qich)后,肠道对细菌的易感性增加,常出现菌群移位,标志此时肠道的免疫防御功能下降。Weber，World J Surg,2003,27(11):1271-1274.第十九页，共四十五页。Peking University School of OncologyHPB Surgical Department脾脏脾脏(pzng)与肝脏的关系与肝脏的关系促进肝细胞合成(hchng)LDH、AKP及白蛋白。有研究表明,脾脏对肝脏Kupffer 细胞具有活化作用。影响Kupffer细胞合成IL-1 和IL-6。Dig Liver Disease,2002,34(2):144.165IL-1、IL-6参与免疫反应，炎症、发热(f r)、急性期蛋质合成 第二十页，共四十五页。Peking University School of OncologyHPB Surgical Department第二十一页，共四十五页。Peking University School of OncologyHPB Surgical DepartmentSplenectomy第二十二页，共四十五页。Peking University School of OncologyHPB Surgical Department脾切除术适应症第二十三页，共四十五页。Peking University School of OncologyHPB Surgical Department脾脏的毗邻(pln)结构第二十四页，共四十五页。Peking University School of OncologyHPB Surgical Department第二十五页，共四十五页。Peking University School of OncologyHPB Surgical Department脾脏(pzng)切除术后发热原因一、感染二、门静脉(jngmi)、脾静脉(jngmi)血栓形成三、脾热第二十六页，共四十五页。Peking University School of OncologyHPB Surgical Department1、感染(gnrn)左膈下脓肿左膈下脓肿(nngzhng)多表现为术后多表现为术后1 2 周体温逐渐周体温逐渐(zhjin)正常后再正常后再度缓慢上升度缓慢上升,直至持续高热直至持续高热,常伴有寒战左季肋区常伴有寒战左季肋区疼痛疼痛,查体时有左季肋区叩击痛。查体时有左季肋区叩击痛。切口感染切口感染的几率较其他开腹手术明显增高膜炎、肺炎0PSI老年患者儿童第二十七页，共四十五页。Peking University School of OncologyHPB Surgical Department脾脏(pzng)切除术后发热原因感染感染(gnrn)左膈下积液左膈下积液表现为术后表现为术后1 2 周体温逐渐正常后再度缓慢上周体温逐渐正常后再度缓慢上升升,直至持续高热直至持续高热,常伴有寒战左季肋区疼痛常伴有寒战左季肋区疼痛(tngtng),查查体时有左季肋区叩击痛。体时有左季肋区叩击痛。CT、B超引导穿刺明确超引导穿刺明确4%-10%第二十八页，共四十五页。Peking University School of OncologyHPB Surgical Department感染(gnrn)的预防引流管一般采用大口径、质地柔韧的胶管,其口径以1.5c m 为宜,前端有多个侧孔。放置引流管时位置非常重要,引流管前端要位于脾窝上方膈下间隙,要保持引流管通畅,不能受压和扭曲。放置引流后要严密注意引流液的数量及性质,经常由上而下挤压。怀疑管胶堵塞(ds)时可轻轻冲洗引流管.只有如此,才不致于被血块或网膜组织堵塞,从而达到有效引流的作用。第二十九页，共四十五页。Peking University School of OncologyHPB Surgical Department脾脏(pzng)的解剖脾脏的毗邻脾脏的毗邻(pln)及韧带及韧带左隔结肠左隔结肠(jichng)韧带解剖韧带解剖第三十页，共四十五页。Peking University School of OncologyHPB Surgical Department左膈结肠左膈结肠(jichng)韧带韧带第三十一页，共四十五页。Peking University School of OncologyHPB Surgical Department左膈结肠(jichng)韧带经结肠脾曲及系膜与后外侧膈肌相连。韧带游离缘中点至后腹壁垂直距离为4-8cm向上扶托脾脏并构成脾窝下方外侧部分韧带下方与左结肠旁沟相通脾切除术后脾窝容积(rngj)平卧位时为200-800ml平均400ml。第三十二页，共四十五页。Peking University School of OncologyHPB Surgical Department放置引流(ynli)方法1、探明左肾位置,保护结肠(jichng)脾曲及膈肌。2、沿膈结肠韧带中点中点至左肾外侧直接剪断该韧带。3、自左肾外侧经左结肠旁沟向脾窝戳孔自左肾外侧经左结肠旁沟向脾窝戳孔。4、置入带侧孔之橡皮管，侧孔同时位于脾床及左侧结肠旁沟再经左下腹壁引出。第三十三页，共四十五页。Peking University School of OncologyHPB Surgical Department2、门静脉(jngmi)、脾静脉(jngmi)血栓 血栓大多起源于脾静脉残余部，可蔓延至门静脉，血栓大多起源于脾静脉残余部，可蔓延至门静脉，如阻塞如阻塞(zs)肠系膜上静脉，则可造成不良后果肠系膜上静脉，则可造成不良后果Hassn等统计等统计(tngj)门静脉血栓者约占脾门静脉血栓者约占脾切除术病人的切除术病人的l0Hassn AM，Br J Burg2000 Mar，87(5)：362-367第三十四页，共四十五页。Peking University School of OncologyHPB Surgical Department门静脉血栓门静脉血栓(xushun)形成时间形成时间 术后第第2 2周周血小板计数达高峰时 临床表现临床表现上腹钝痛、恶心、呕吐、血便、体温升高、白细胞计数增多及血沉加快 预防治疗预防治疗术后血小板计数1000 x109L时应用肝素等抗凝剂Hassn AM，Br J Burg2000 Mar，87(5)：362-367第三十五页，共四十五页。Peking University School of OncologyHPB Surgical Department第三十六页，共四十五页。Peking University School of OncologyHPB Surgical Department3、脾热 脾切除术后的不明(b mn)原因发热,是一种复杂的临床表现,体温升高可达38-39,常持续1 2 周,可达2 4 周或更久,临床上大多不能发现引起发热的原因,经过一段时间可逐渐恢复正常,应用抗生素的治疗效果不明显。第三十七页，共四十五页。Peking University School of OncologyHPB Surgical Department脾热的诊断(zhndun)B超、超、CT 等检查等检查排除排除膈下积液或感染、肺炎、膈下积液或感染、肺炎、肺不张、胸腔积液、门静脉血栓肺不张、胸腔积液、门静脉血栓(xushun)形成。形成。血白细胞及中性粒细胞属正常或稍高水平，血白细胞及中性粒细胞属正常或稍高水平，中细胞无明显核左移中细胞无明显核左移。使用非甾体类解热药疗效好使用非甾体类解热药疗效好,如吲哚美辛、消如吲哚美辛、消炎痛等。炎痛等。第三十八页，共四十五页。Peking University School of OncologyHPB Surgical Department脾切除后免疫(miny)功能继发性缺陷巨噬细胞活性下降,尤其对未能调理的颗粒淋巴细胞在血中停留的时间延长血清IgM 减少补体旁路活性下降T uft sin 产生减少自身抗体活性增强T细胞减少，T、B 淋巴细胞间协同性降低红细胞膜C3b 受体粘附(zhn f)性降低红细胞免疫功能受损第三十九页，共四十五页。Peking University School of OncologyHPB Surgical Department脾热的原因(yunyn)脾脏切除术后,脾脏的滤过功能消失,机体的免疫防护和自身稳定功能下降,处理和清除大分子物质和抗原能力下降.一些致热性物质,尤其是内源性致热源(主要通过淋巴因子刺激大单核细胞产生内源性致热引起发热),不能有效而完全的灭活和排除,可作用于体温调节中枢,使体温调定点升高,体温上升。再者,脾脏切除后,形成特异性抗体和免疫球蛋白减少。调理(tio l)素的产生及其作用均受到影响而引起发热.第四十页，共四十五页。Peking University School of OncologyHPB Surgical Department3/32patientsserumundiluted portal vein diluted to 1:8 vein of the ear portal veinvein of the ear no fever fever fever fever no fever serum withleucocytes Chan Mo-Wah,A.J.S.McFadzean Volume 68,Issue 6,Pages 437-446 第四十一页，共四十五页。Peking University School of OncologyHPB Surgical Department PsF is the consequence of the removal of the only source of an antigen which mops up leucocyte autoagglutinin produced elsewhere and in the spleen.If there is any limited spill-over of the autoagglutin in the experimental，evidence suggests that this can be filtered off by the liver and the lungs.if the spleen is stimulated to contract autoagglutinin appears in low titres in the peripheral blood.The experimental evidence indicates that the spleen can inhibit or destroy leucocyte pyrogen Post-splenectomy Fever第四十二页，共四十五页。Peking University School of OncologyHPB Surgical Department脾热的治疗(zhlio)1、应用消炎痛消炎痛进行(jnxng)治疗，可取的较好的疗效，体温大多数可在3-5天后将至正常或基本正常。2、消炎痛是吲哚类解热镇痛药物，主要是用于一些免疫系统疾病和一些恶性疾病的发热，这也是免疫系统障碍致使脾热的佐证之一。第四十三页，共四十五页。Peking University School of OncologyHPB Surgical Department谢谢(xi xie)第四十四页，共四十五页。内容(nirng)总结脾切除术后发热 Post-splenectomy Fever。正常情况下脾脏通过其自身拥有的丰富的免疫细胞及免疫因子对肠道发挥作用。表现为术后1 2 周体温逐渐正常后再度缓慢上。放置引流后要严密注意引流液的数量及性质,经常由上而下挤压。2、沿膈结肠韧带(rndi)中点至左肾外侧直接剪断该韧带(rndi)。3、自左肾外侧经左结肠旁沟向脾窝戳孔。血栓大多起源于脾静脉残余部，可蔓延至门静脉，如阻塞肠系膜上静脉，则可造成不良后果。谢谢第四十五页，共四十五页。