摘要
目的Rex手术（肠系膜上静脉与门静脉左支矢状部搭桥分流手术）是治疗肝外门静脉海绵变导致门静脉高压的最流行术式，但是有大约14％的患者合并有门静脉矢状部闭锁或发育不良不能行此分流手术，并且此手术后的失败率在4％～28％，这限制了这种符合生理性分流手术的应用。本研究的目的是探索向肝内门静脉右支分流建立恢复门静脉血流的新途径。方法2015年11月至2016年6月，对4例门静脉海绵样变性行Rex分流手术后门脉高压复发患儿行门静脉右支分流手术。患儿年龄3．5～8．9岁，平均6．1岁，分别于1．1～2．5年前在我院行Rex手术，其中采用扩张的胃冠状静脉与肝内门静脉矢状部搭桥3例，扩张的门静脉主干分支与肝内门静脉矢状部搭桥1例，术后再发出血和脾功能亢进，经保守治疗无效。术前影像学检查提示：食管胃底静脉曲张，门静脉海绵样变存在；原搭桥血管显示不清，肝内门静脉血流少；脾脏增大。手术采用原上腹肋缘下横切口，首先游离肝门的了解原搭桥血管的形态；然后将胆囊从胆囊床上游离；在右侧肝门的后方切开Glisson氏鞘，显露门静脉右支，将其游离足够的长度；然后切开肝十二指肠韧带，游离扩张门静脉主干足够的长度；根据肝内门静脉右支至肝外门静脉主干之间的距离，截取肠系膜下静脉作为搭桥血管：血管壁外观正常，直径≥5mm;以7-0 Prolene线将间置静脉的近心端和远心端分别与门静脉右支和肝外门静脉的主干行端侧吻合。术后1个月、3个月及6个月定期随访。结果4例患儿中3例门静脉右支发育好、通畅，直径5～6mm，成功实施门静脉右支搭桥手术；另外1例门静脉右支纤细放弃搭桥。手术时间2．3h（1．9～3．5h），术中出血约50ml（30~80ml），无一例需要输血。取肠系膜下静脉间置3例；搭桥后门静脉的平均压力由33cmH2O（26~45cmH2O）下降至18．7cmH2O（14～24cmH2O）。术中发现肝内门静脉右支与左支延续相通，而与肝外门静脉主干中断不通；Glisson鞘内沿着胆管周围大量增生的小静脉；原搭桥血管呈条索状，一致性狭窄或闭锁。术后随访6～18个月，无患儿再出现呕血，影像学检查分流血管增粗通畅，肝内门静脉增粗，门静脉海绵样改变消失，肝功能各项指标正常；血小板、红细胞血红蛋白、白细胞正常。结论门静脉主干与肝内门静脉右支分流是治疗肝外型门静脉高压的有效新方法，适用于门静脉左支发育不良或Rex手术失败的病例，目前该方法尚未见文献报告。
Objective Original Rex shunt （mesenteric-to-left portal vein bypass） has been employed successfully for treating patients with extrahepatic portal vein obstruction. However, about 14% of children with extrahepatic portal vein obstruction suffered left portal vein agenesis and 4% to 28% patient had failed Rex shunt. Rex shunt became impossible for them. This study reports a novel approach of using portal-right portal vein bypass for treating extrahepatic portal vein obstruction after failed Rex shunt. Methods Four patients with failed Rex shunt underwent portal-right portal vein bypass. Their mean age was 6. 1 （3. 5-8. 9） years. Primary Rex shunt was performed 1.1 to 2. 5 years ago. Postoperatively, they developed recurrent gastrointestinal bleeding and hypersplenia not responding to conservative measures. After confirmation of blocked original shunt by dissection,cavernoma was bypassed by interposing a venous inferior mesenteric vein autograft between main portal vein in hepatoduodenal ligament and right portal vein. Results In 3/4 patients, right portal vein was well-developed with a diameter of 5 to 6 mm and another right portal vein became agenesic. Portal- right portal vein bypass was successfully conducted in 3 patients. Operative duration was 2. 3（1.9-3. 5） hours and bleeding volume was 50（30-80） ml without blood transfusion. After shunting, portal vein pressure decreased from 33 （26 45） to 18. 7 （14-24） cmH20. During a median follow-up period of 0. 9 （0. 5-1.5） years, there was no recurrence of gastrointestinal bleeding or hypersplenia after bypass. Postoperative DoppIer and computed tomographic angiography confirmed shunt patency and satisfactory blood flow in shunts. Conclusions Direct bypass of portal cavemomata by right portal vein is efficacious for portal hypertension in children with failed Rex shunt. Patients with left portal vein agenesis or failed Rex shunt may benefit from this procedure. To our knowledge, this is the first report of treating extrahepatie portal vein obstruction via right portal vein bypass.
出处
《中华小儿外科杂志》
CSCD
2017年第8期580-584,共5页
Chinese Journal of Pediatric Surgery
作者简介
通信作者：李龙，Email：lilong23@126．com
