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1、Peking University School of OncologyHPB Surgical Department脾切除术后发热脾切除术后发热 Post-splenectomy Fever 刘茂兴Peking University School of OncologyHPB Surgical Department 术后发热机理病原菌免疫力免疫力发热发热Peking University School of OncologyHPB Surgical Department术后发热原因术后发热原因 术后体温低38 3天后将至正常超过38，持续不退, 或者一度降至正常, 又突然上升，一般在术后4
2、-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Peking University School of OncologyHPB Surgical Department脾切除术后高热、感染的发生率远脾切除术后高热、感染的发生率远超过胃大部切除、单纯胆囊切除术超过胃大部切除、单纯胆囊切除术whyPeking University School of OncologyHPB Surgical Department脾脏的解剖生理生命阳光尊严Peking University School of OncologyHPB Surgical Department脾脏的发生Peking U
3、niversity School of OncologyHPB Surgical Department脾的发生Peking University School of OncologyHPB Surgical DepartmentPeking University School of OncologyHPB Surgical DepartmentPeking University School of OncologyHPB Surgical Department脾脏的组织学结构白髓（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
4、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。Peking University School of OncologyHPB Surgical DepartmentWhite PulpRed PulpHistologic features of the Spl
5、eenPeking University School of OncologyHPB Surgical DepartmentCordsSinusRed Pulp HistologyPeking University School of OncologyHPB Surgical DepartmentMantle zoneMarginal zoneGerminalcenterPeking University School of OncologyHPB Surgical DepartmentPeking University School of OncologyHPB Surgical Depar
6、tment脾脏功能一、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、脾脏与肝脏的关系脾脏与肝脏的关系五、五、脾脏与肠道脾脏与肠道六、血脾屏障六、血脾屏障Peking University School of OncologyHPB Surgical Department脾脏免疫功能非特异性免疫功能非特异性免疫功能 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）Peking University School of OncologyHPB Surgical Department免疫
7、功能组成 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。Peking University School of OncologyHPB Surgical Department脾脏的分泌功能 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, 增强机体抗感染和肿瘤的体液免疫反应。tuftsinPeki
8、ng University School of OncologyHPB Surgical Department脾脏与肠道脾脏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.Peking University School of OncologyHPB Surgical Department脾脏与肝脏的关系脾脏与肝脏的关系促进肝细胞合成LDH、AKP及白蛋白。有研究表明,
9、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。IL-1、IL-6参与免疫反应，炎症、发热、急性期蛋质合成 Peking University School of OncologyHPB Surgical DepartmentPeking University School of OncologyHPB Surgical DepartmentSplenectomyPeking University School of OncologyHPB Surgical Department脾切除术适应症Peking University School of
10、 OncologyHPB Surgical Department脾脏的毗邻结构Peking University School of OncologyHPB Surgical DepartmentPeking University School of OncologyHPB Surgical Department脾脏切除术后发热原因一、感染二、门静脉、脾静脉血栓形成三、脾热Peking University School of OncologyHPB Surgical Department1、感染左膈下脓肿左膈下脓肿多表现为术后多表现为术后1 2 周体温逐渐正常后再度周体温逐渐正常后再度缓慢上
11、升缓慢上升, 直至持续高热直至持续高热, 常伴有寒战左季肋常伴有寒战左季肋区疼痛区疼痛, 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Peking University School of OncologyHPB Surgical Department脾脏切除术后发热原因感染感染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, 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
12、引导穿刺明确超引导穿刺明确4%-10%Peking University School of OncologyHPB Surgical Department感染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。Peking University School of OncologyHPB S
13、urgical Department脾脏的解剖脾脏的毗邻及韧带脾脏的毗邻及韧带左隔结肠韧带解剖左隔结肠韧带解剖Peking University School of OncologyHPB Surgical Department左膈结肠韧带左膈结肠韧带Peking University School of OncologyHPB Surgical Department左膈结肠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平卧位时为200-800ml平均400ml。Peking Univ
14、ersity School of OncologyHPB Surgical Department放置引流方法1、探明左肾位置, 保护结肠脾曲及膈肌。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。Peking University School of OncologyHPB Surgical Department2、门静脉、脾静脉血栓 血栓大多起源于脾静脉残余部，可蔓延至门静血栓大多起源于脾静脉残余部，可蔓延至门静脉，脉，如阻塞肠系膜上静脉，则可造成不
15、良后果如阻塞肠系膜上静脉，则可造成不良后果Hassn等统计门静脉血栓者约占脾切等统计门静脉血栓者约占脾切除术病人的除术病人的l0Hassn AM，Br J Burg2000 Mar，87(5)：362-367Peking University School of OncologyHPB Surgical Department门静脉血栓门静脉血栓 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 M
16、ar，87(5)：362-367Peking University School of OncologyHPB Surgical DepartmentPeking University School of OncologyHPB Surgical Department3、 脾热 脾切除术后的不明原因发热, 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。Peking University School of OncologyHPB Surgical Department脾热的诊断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、门静脉血栓形成。肺不张、胸腔积液、门静脉血栓形成。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、如吲哚美辛、消炎痛等。消炎痛等。Peking U
