肠系膜上静脉门静脉左支分流术治疗肝外门脉高压

目的 探讨肠系膜上静脉门静脉左支分流术治疗肝外门静脉梗阻的效果.方法 2008年10月至2010年2月对12例肝外门脉梗阻并门脉高压患儿实施肠系膜上静脉门静脉左支分流术(mesenteric-to-left portal vein bypass,MLPVB;又称Rex Shunt,RS手术).2例因门静脉左支闭锁,无法吻合,实施远端脾肾分流术(Warren手术).RS手术患儿年龄1.6～12岁,平均(5.6±3.3)岁.男8例,女2例.7例患儿有反复呕血、黑便史,输血史,输血量800～2400 ml;另外3例患儿表现巨脾、脾功能亢进、进行性贫血.8例患儿术前红细胞、白细胞、血小板降低;2例AST轻度升高,1例TBIL轻度升高,其他患儿各项指标正常;无脑病表现.术前影像学检查提示:10例表现食道胃底静脉曲张,门脉海绵样变;脾脏增大,脾脏平均长径(n=8)(12.4±0.8)cm,厚度(5.1±0.57)cm.手术采用上腹肋缘下横切口,测定肠系膜上静脉压力,并行门脉造影.分离矢状部肝组织,游离肝门静脉左支,穿刺测压并造影,确认门静脉左支通畅,阻断钳阻断并纵行劈开矢状部.根据门脉造影及探查情况选择游离胃冠状静脉、或脾静脉或移植一段合适的回肠静脉.然后以6-0 Prolene线将胃冠状静脉、脾静脉与门静脉左支行端侧吻合,移植血管一端与门静脉左支矢状部吻合另一端与门静脉远端吻合.再次测定肠系膜上静脉压力,并行血管造影.术后随访4～20个月.结果 10例患儿均成功实施手术,平均手术时间(220±14.7)min,出血约10～50 ml,分流完成后造影显示分流血管均通畅无狭窄.分流前门脉平均压力(38.3±7.2)cm H2O,分流后降为平均(27.2±5.3)cm H2O,(P=0.001).平均住院时间(10±1.9)d.随访期间无患儿再出现呕血,影像学检查分流血管通畅,肝功能各项指标正常;血小板、红细胞血红蛋白、白细胞正常;脾脏较术前缩小,脾脏平均长径(n=8)(10.2±0.5)cm,较术前缩小(P=0.00),平均厚度(3.6±0.2)cm,较术前缩小(P=0.000),门静脉左支直径增大.结论 Rex分流术治疗门静脉海绵样变性安全、可行、效果良好.

Rex shunt for extrahepatic portal hypertension in children with extrahepatic portal vein obstruction.

Objective To review the efficacy and safety of Rex shunts for patients with extrahepatic portal vein obstruction (EHPVO). Methods Ten children with extra-hepatic portal vein obstruction (EHPVO) operated between October 2008 and February 2010 were reviewed. There were 8boys and 2 girls. Their ages ranged from 19 to 144 months. Seven of the patients suffered from recurrence upper gastro-intestinal (GI) bleeding, and 3 from splenomegaly and hypersplenism. Upper GI radiography (UGIR) demonstrated esophageal and gastric varices (EGV). Ultrasonograph (US) also showed EHPVO. All patients underwent mesenteric-to-left portal vein bypass (MLPVB). Patients were followed up 4-20 (average: 9. 6 ±5.0 ) months. Results The mean duration of operation was 220 ± 14. 7 minutes (range: 200 to 240) without intraoperative complication. Operative blood loss was 10 to 50 ml with no need for blood transfusion. Portal pressure decreased after Rex shunt. The postoperative course was uneventful in 10 patients with hospital stay ranging from 8 to 15days. There was no further gastrointestinal bleeding. The spleen size dccreased,The platelet counts and white blood cell counts increased, and there was no postoperative complication during the followed-up period. Conclusions Rex shunt for patients with EHPVO is feasible, safe and effective.