Rex术后再发生上消化道出血的治疗策略探讨

目的 探讨小儿肝外门静脉高压Rex术后再发生上消化道出血时的治疗策略.方法 回顾性分析2008年6月至2017年1月126例门静脉海绵样变行Rex手术治疗患儿中,26例Rex术后再次出现呕血、黑便等上消化道出血表现患儿的临床资料.其中,113例患儿门静脉血管超声和CT显示未见明显分流血管,10例分流血管明显狭窄,3例门静脉血管超声可见分流血管通畅.21例患儿行上消化道造影检查,其中20例食管静脉曲张.采用输血止血等保守治疗10例.行Warren术治疗5例,其中1例先行Rex术治疗失败后改行Warren术.行Rex术治疗8例,其中1例失败,最终行Warren术治疗;1例先行内镜下硬化剂治疗后再出血,改行Rex术治疗.行肠系膜下静脉间置、门静脉主干-门静脉右支分流术1例.1例吻合口狭窄患儿行吻合口扩大成形术.行内镜下硬化剂治疗3例,1例术后再次出血后行Rex术治疗.所有患儿定期随访及复查.结果 行Rex术、Warren术和保守治疗患儿上消化道出血复发率分别为62.5％ (5/8)、20％(1/5)和90％(9/10),食道胃底静脉曲张率分别为75％(6/8)、20％(1/5)和100％,均以行Warren术患儿最低,三组比较,差异均有统计学意义(P=0.027和0.015).比较行Rex术、Warren术和保守治疗患儿术后随访时间(22.9±24.4)个月、(26.6±24.1)个月和(26.0±20.4)个月],三组差异无统计学意义(P=0.939).行Rex术和Warren术患儿术后分流血管通畅率分别为62.5％(5/8)和100％,组间差异无统计学意义(P=0.118).保守治疗10例,其中1例分流血管通畅者迄今随访43个月未再出血,其余患儿均出现呕血或黑便.接受内镜下硬化剂治疗3例,其中1例分流血管闭锁者术后再次呕血行Rex手术治疗.结论 Warren术是治疗Rex术后复发的有效手术方法.保守治疗及内镜下硬化剂治疗仅适用于分流血管通畅的患儿,对于分流血管狭窄或闭锁的患儿应积极手术治疗.

Therapeutic strategies for recurrent upper gastrointestinal hemorrhage in children undergoing Rex shunting

Objective To explore the therapeutic strategies for re-bleeding children after Rex shunting.Methods From June 2008 to January 2017,126 children with portal cavernous underwent Rex shunting.And 26 children had a recurrence of upper gastrointestinal hemorrhage.Occluded bypass veins were detected by postoperative ultrasound or computer tomography (CT) in 13 children.There were stenosis of bypass vein (n =10) and patency of bypass vein (n =3).Upper gastrointestinal imaging was performed in 21 children and esophageal varices detected in 20.Transfusion and hemostasis were offered for 10 children and Warren shunting was performed (n =5).One child suffered from re-bleeding after a second Rex shunt and required conversion into Warren shunt.A second Rex shunt was performed in 8 children (one underwent a conversion to Warren shunt ultimately and one underwent endoscopic sclerotherapy before a second Rex shunt).One child underwent main portal vein-right portal vein with interposition of inferior mesenteric vein.One child underwent venoplasty of bypass vein after failed conservative therapy and three children received endoscopic sclerotherapy (ES) (one underwent a conversion into a second Rex shunt).Results The rates of postoperative rebleeding and esophageal gastric varices were significantly different among children undergoing Rex shunt,Warren shunt and conservative therapy.It was the lowest in Warren shunt (rate of postoperative rebleeding:62.5％ vs 20％ vs 90％,P =0.027;rate of esophageal gastric varices:75％ vs 20％,100％,P =0.015).No significant difference existed in follow-up duration among children undergoing Rex shunt,Warren shunt conservative therapy (22.9 ± 24.4) vs (26.6 ± 24.1) months vs (26.0 ± 20.4) months,P =0.939].No significant difference existed in rate of bypass vein patency among children undergoing Rex shunt and Warren shunt (62.5％ vs 100％,P =0.118).One quarter of ten children undergoing conservative therapy had no rebleeding during a follow-up period of 43 months.One child had a patent bypass vein while other nine children with an occluded or narrowed bypass vein suffered from rebleeding.Conclusions Warren shunt is effective for Rex shunt.Conservative therapy and ES are recommended for children with patency of bypass vein.And surgery is reserved for those with occluded or narrowed bypass vein.