远端脾肾静脉分流手术治疗肝外型门脉高压的探讨

Exploration of Treatment for Extrahepatic Portal Hypertension by a Distant Splenorenal Venous Shunt Operation

目的探讨保留脾脏、远端脾静脉肾静脉分流手术治疗肝外型门脉高压的效果。方法本组手术患儿15例,术前经多普勒超声检查门静脉主干呈海绵窦样改变。术中首先经小肠系膜Ⅲ级静脉和脾静脉分支行静脉压力测定及造影。然后将胰腺上下缘及背侧游离;将胰腺内走行的脾静脉游离,结扎切断与胰腺之间的细小分支,远端至脾静脉与肠系膜上静脉或肠系膜下静脉汇合处,近端至脾门;最后将脾静脉距肠系膜上或下静脉0.5cm处切断,闭合肠系膜上静脉侧断端,将脾静脉与左肾静脉端一侧吻合;同时结扎胃冠状静脉、胃左静脉和胃网膜左静脉而保留胃短血管。结果15例患儿实施远端脾-肾分流手术,手术时间平均3.5h,手术失血10～30ml;无需输血者。分流前肠系膜上静脉和脾静脉压力平均值分别为28.4cmH2O和28.1cmH2O,分流后平均值分别为24.7cmH2O和12.6cmH2O,脾静脉压力明显降低(P<0.01)。分流后脾脏缩小,被膜皱缩。2例手术后患儿出现乳糜腹,保守治疗1个月后自然消失。患儿随诊6个月～2年无再发消化道出血者,脾脏大小均回缩。血红蛋白、白细胞、血小板均在正常水平。超声多普勒检查,脾肾静脉吻合口通畅。结论远端脾静脉-肾静脉分流术是治疗小儿肝外型门静脉高压的有效途径之一,具有保留脾脏。

Objective To explore efficacy of treatment for extrahepatic portal hypertension secondary to extrahepatic portal vein obstruction by a distant splenorenal venous shunt operation under spleen conservation. Methods 15 Cases of EPVP in the group were involved,their age from 15 to 17 years old ,including 14 boys,11girls. Dopple ultrasonic examination has shown that there was cavernous sinos pathologic alteration in the main stem of hepatic portal veins.The venous pressure in the mesenteric veins grade Ⅲ,and spleen veins branches were recorded and the imaging. Then we freed the margins of superior,inferior and the dorsal side of pancreas.At same time ,we also freed the spleen vein existed in the pancreas .The fine branches of spleen veins were ligated,and removal the branches associated with pancreas;at distant end to convergece zone of spleen vein associated with mesenteric superior veins or with inferior veins,at short end to hilum of spleen.Final,severed the spleen veins at a distant 0.5 cm site from mesenteric superior veins or inferior veins.Closed the severed end of mesenteric superior veins,spleen vein and left renal vein was anastomosed.simultaneously, the gastric coronary veins,gastric left veins and gastric omental left veins were ligated,but keeping the gastric short blood vessels. Results A distant spleen-renal shunt operation were performed, the operation average duration was 3.5h,operation hemorrhage:10～30ml,the sick children didn't need to be blood transfusion. The average values of the superior vein and the spleen venuous pressures were 28.4cm H2O column and 28.1cm H2O column respectively before the shunt operation.After the shunt operation,the average values were 24.7cm H2O column and 12.6cm H2O column respectively ,the venuous pressure was decreased obviously,spleen size and capsule crease area also were markable reduced.The operation has some complications: such as,the two sick children occurred chyloperitoneum after the operation ,but the complication was disappeared natunal after conservation therapy one month .All the sick children were followed up for 6 months to two years ,no alimentary tract bleeding was seen,spleen size was reduced,values of Hb,WBC,platelets count were all normal.Dopple ultrasonic examination showed that the splenorenal venous anastomotic stoma was unobstructed. Conclusions This findings suggest that a distant splenorenal venous shunt operation is an effective technique to treat the extrahepatic portal hypertension in young children.Our consider that the operation has some merits; for example,it can conserve the spleen,keeping pressure status in the area ,where is blood of cardia fundus-gastric base passed the gastric short arteria flows to spleen vein site The procedure also could prevent the reoccurence of alimentary tract bleeding,and the venous pressure of mesenteric superior vein is not decreased.