Warren手术治疗小儿门脉高压

Warrens operation： an 8 year experience

目的总结过去8年采用保留脾脏、远端脾静脉肾静脉分流手术（Warren手术）治疗小儿门脉高压的效果。方法本组患儿36例，年龄3～15岁，男12例，女24例。患儿表现为反复消化道出血，食管静脉曲张，脾功能亢进。门静脉主干呈海绵窦样改变29例，Carolis病合并肝纤维化2例，先天性肝纤维化5例，Child-pugh评分均为A级（5～7分），脾静脉的直径6．5～12．2mm，平均为（8．6±2．3）mm。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。然后将整个脾静脉游离，距肠系膜上静脉0．5cm处切断，与左肾静脉端－侧吻合。结果36例患儿实施远端脾肾分流手术，平均手术时间3．1h，手术失血10～30ml；无术中需输血者。分流前肠系膜上静脉压力为26．5～33．3cmH2O，平均值为（28．9±4．8）cmH2O，脾静脉压力为26．2～33．5cmH2O，平均值为（28．5±4．5）cmH2O；分流后肠系膜上静脉压力为17．2～26．4cmH2O，平均值为（23．8±3．9）cmH2O，脾静脉压力为10．5416．1cmH2O，平均值为（13．5±4．7）cmH2O，分流手术后脾静脉压力明显降低（P〈0．01）。手术后2例患儿出现乳糜腹，保守治疗1个月后自然消失。随诊6～94个月，1例（1／36）手术后3个月吻合口闭合，行脾切除和断流手术。其他35例随访期内无再发消化道出血者，脾脏尽管比正常同龄儿童稍大，但均回缩，且血红蛋白、自细胞、血小板均在正常水平，未出现脑病者。B超检查，脾肾静脉吻合口通畅。结论Warren手术是治疗小儿肝外型门静脉高压的有效途径之一，预防消化道再出血和脾功能亢进效果可靠，同时具有保留脾脏，贲门胃底血流可通过胃短动脉流向脾静脉使该区域保持低压状态，不降低门静脉灌注压力等优点。

Objective To review our experience with Warren shunt and to define its role in the management of variceal bleeding. Methods From October 1999 to August 2007, 36 children with variceal bleeding underwent Warren shunt operation. The age ranged from 3 to 15 years （ mean 8. 2 years）. 29 patients suffered from cavernomatous portal vein, 2 Carolis disease with hepatic fibrosis and the other 5 congenital hepatic fibrosis. The mean diameter of the splenic vein was 8. 6 ＋ 2. 3 mm （6. 5- 12. 2 mm）. Results The distal splenorenal shunt was performed in the 36 cases. The mean operating time was 3. 1 hours without necessity for blood transfusion. There was no operative mortality. The pre-shunt pressures of portal vein and splenic vein were 28. 9 ±4. 8 cmH2O（26. 5-33. 3 cmH2O） and （28. 5± 4. 5） cmH2O（26. 2-33. 5 cmH2 O） respectively. However after shunting, the pressures decreased to 23. 8± 3. 9 cmH2O（ 17. 2-26. 4 cmH2O）and 3.5 ± 4. 7 cmH2O （10. -16.1 cmH2O）respectively. The pressure of the splenic vein after the operation was significantly decreased than that before the operation, P〈0. 01. One patient has anastomosic stricture and underwent splenectomy and branch ligation 3 month after the shunt. The remaining 35 patients were alive at a median follow-up of 53 months （range 6 to 94 months） without evidences of recurrent gastrointestinal bleeding, hyper- splenism or encephalopathy. Conclusions The distal splenorenal shunt is a safe and effective therapy for children with portal hypertension.