三联手术治疗小儿肝外门静脉高压

TRIPLEX OPERATIONS FOR CHILDREN WITH EXTRAHEPATIC PORTAL HYPERTENSION

目的 评价脾肺固定术 +断流术 +脾动脉结扎术治疗小儿门脉高压的疗效。 方法 1993年 3月～1998年 11月对 7例确诊为门脉高压的患儿行三联手术治疗。测定手术前后白细胞、血小板计数和肝功能 ,脾动脉结扎前后游离门静脉压。术后随访 2～ 8年 ,平均 5 .6年。记录上消化道出血的发生情况 ,并采用钡餐评定食管胃底静脉曲张的程度。 B超测定脾脏和门静脉直径 ,以彩色多普勒血流显像测定门肺分流及门静脉血流 ,粘度计行血液流变学检测。结果 本组无手术死亡。术后食管及胃底曲张静脉的出血被完全控制。白细胞及血小板计数恢复至正常水平 ,脾脏直径进行性缩小。静脉曲张趋于缓解 ,游离门静脉压由术前 ( 4 2 .6 2± 6 .72 ) cm H2 O降至术后 ( 34.4 8± 5 .71) cm H2 O,差异有统计学意义 ( P<0 .0 5 )。门静脉血流量亦降低 ,其血流方向至肝 ;脾静脉血流方向至脾。术前全血粘滞度降低 ,术后恢复至正常水平。

Objective To evaluate the effect of triplex operations (splenopneumopexy, portal azygous devascularization and ligation of splenic artery) for children with extrahepatic portal hypertension. Methods From March 1993 to November 1998, 7 children with extrahepatic portal hypertension underwent triplex operations. The diagnosis for these patients were confirmed by gastroscopy, barium meal and Doppler ultrasonography. The number of WBC and platelet and the hepatic function were checked before and after operations. And the free portal pressures were checked before and after ligations of the splenic artery. All patients were followed up for 2 to 8 years (5.6 years on average). The episodes of upper gastrointestinal bleeding were recorded. The degrees of varices of distal esophagus and proximal stomach were assessed by barium meal and gastroscopy. The diameters of the splenic and portal veins were obtained by B ultrasound. The portopulmonary shunt and portal blood flow were evaluated by color Doppler flow image. The indices of hemorheology such as hematocrit, viscosity of whole blood and plasma, and the index of deformability and aggregability of RBC were obtained through viscometer (R 20 Seerle, Beijing). Results There was no operative fatal case in this group. Postoperatively, hemorrhage from the esophagus and gastric varices was completely controlled. Although the diameter of spleen reduced progressively, no patient's spleen recovered to normal size during the follow up period. The degree of varices was mitigated and the free portal pressure was significantly decreased to (34.48±5.71) cm H 2O from the preoperative one (42.62±6.72) cm H 2O ( P< 0.05). The rate of portal flow was also decreased. The direction of portal vein was bidirection (one part was away from the liver and the other was toward the liver). The number of WBC and platelet and the viscosity of whole blood and hematocrit were increased to normal value after operation. Conclusion The triplex operation is an effective procedure for the control of hemorrhage from varices in children with extrahepatic portal hypertension.