儿童门静脉高压Rex手术后发生血管并发症的相关因素研究

Influencing factors of vascular complications after Rex operation in children with portal hypertension

目的探讨儿童门静脉高压Rex手术(Meso-rex bypass)后发生血管并发症的相关因素及其临床启示。方法回顾性分析2014年10月至2021年4月在广州市妇女儿童医疗中心完成首次Rex手术的95例肝外型门静脉高压患儿临床资料。术后血管并发症定义为:搭桥血管栓塞或吻合口狭窄。Rex手术后发生搭桥血管栓塞或吻合口狭窄者归入血管并发症组,未发生搭桥血管栓塞或吻合口狭窄者归入无血管并发症组。采用单因素分析及Cox多因素回归模型分析Rex手术后发生血管并发症的相关因素。结果95例患儿中,无血管并发症组81例;血管并发症组14例,包括吻合口狭窄10例、血管栓塞4例。两组手术前后血小板计数差值比较:血管并发症组[(2.47±12.61)×10^(9)/L]低于无血管并发症组[(63.35±54.54)×10^(9)/L],差异有统计学意义(t=8.677,P<0.001);脾长径手术前后差值比较:血管并发症组[(9.38±24.16)mm]短于无血管并发症组[(23.20±20.65)mm],差异有统计学意义(t=2.299,P=0.024);脾厚度手术前后差值比较:血管并发症组[(1.95±7.11)mm]小于无血管并发症组[(8.95±9.13)mm],差异有统计学意义(t=2.782,P=0.007)。95例患儿按患病时间长短分为患病时间≤16个月组(60例)、患病时间>16个月组(35例),两组术后2年血管通畅率分别为93.3%(56/60)和71.4%(25/35),差异有统计学意义(P=0.010);按移植血管为腹腔内血管或颈内静脉分为腹腔内血管组(13例)和颈内静脉组(82例),两组术后2年血管通畅率分别为30.8%(4/13)、93.9%(77/82),差异有统计学意义(P<0.001);按手术前后门静脉压力差的大小分为≤2 mmHg(1 mmHg=0.133 kPa)组(9例)和>2 mmHg组(86例),两组术后2年血管通畅率分别为44.4%(4/9)和89.5%(77/86),差异有统计学意义(P<0.001);将单因素中有统计学意义的因素进行多因素分析发现,患病时间(P=0.036)、手术前后门静脉压力差(P=0.048)以及移植血管种类(P<0.001)是Rex手术后发生血管并发症的独立相关因素。结论Rex手术是治疗儿童肝外型门静脉高压的理想术式,可重建入肝血流,并有效改善门静脉高压相关症状;患儿患病时间、手术前后门静脉压力差、移植血管种类是Rex手术后发生血管并发症的独立相关因素。

Objective To explore the related factors and clinical implications of affecting the occurrence of vascular complications after Rex surgery(Meso-rex bypass).Methods From October 2014 to April 2021,clinical data were retrospectively reviewed for 95 children of extrahepatic portal hypertension(EHPVO)undergoing an initial Rex operation.Postoperative vascular complications were defined as bypass vascular embolism and anastomotic stenosis.Two groups of vascular complication(n=14)and non-complication(n=81).Univariate analysis and Cox multivariate regression model analysis were utilized for determining the influencing factors of the occurrence of vascular complications after Rex.Results There were anastomotic stenosis(n=10,10.5%)and vascular embolism(n=4,4.2%);Comparing parametric differences before and after operation:platelet count:[complication group(2.47±12.61)×10^(9)/L was lower than non-complication group(63.35±54.54)×10^(9)/L,the difference was statistically significant(t=8.677,P<0.001)];splenic length:[complication group(9.38±24.16)mm was shorter than non-complication group(23.20±20.65)mm,the difference was statistically significant(t=2.299,P=0.024)];spleen thickness:[complication group(1.95±7.11)mm was smaller than non-complication group(8.95±9.13)mm,the difference was statistically significant(t=2.782,P=0.007)].Based upon duration of illness,they were divided into two groups of≤16 months(n=60)and>16 months(n=35).Vascular patency rates at 2 years post-operation were 93.3%(56/60)and 71.4%(25/35)and the difference was statistically significant(P=0.010).According to the choice of transplanted blood vessels,they were assigned into two groups of intra-abdominal vessels(n=13)and internal jugular veins(n=82).Vascular patency rates were 30.8%(4/13)and 93.9%(77/82)and the difference was statistically significant(P<0.001).According to portal vein pressure difference before and after operation,they were divided into two groups of portal vein pressure difference≤2 mmHg(n=9)and>2 mmHg(n=86).Vascular patency rates at 2 years post-operation were 44.4%(4/9)and 89.5%(77/86)and the difference was statistically significant(P<0.001).Multivariate analysis of significant single factors revealed that duration of illness(P=0.036),portal pressure difference before and after operation(P=0.048)and type of transplanted blood vessel(P<0.001)were independent occurring factors of vascular complications after Rex.Conclusion Rex surgery is an ideal treatment of extrahepatic portal hypertension in children.It can reconstruct blood flow into liver and effectively improve the symptoms of portal hypertension.Duration of illness,difference in portal pressure before and after surgery and type of transplanted blood vessels affect blood vessels after Rex.