腹腔镜脾切除联合胃食管周围血管离断术治疗小儿门静脉高压症

Laparoscopic splenectomy and periesophagogastric devascularization with endoligature for portal hypertension in children

目的报告内结扎法腹腔镜脾切除联合胃食管周围血管离断术治疗小儿门静脉高压症合并出血和脾功能亢进的经验及效果。方法本组6例，男5例，女1例，年龄8～17岁。采用丝线内结扎法结合超声刀进行腹腔镜脾切除和选择性贲门周围血管离断术，切除巨脾后，离断胃食管周围侧支血管和穿支静脉，保留胃冠状静脉和食管旁静脉向奇静脉的分流。结果手术均在腹腔镜下完成，手术时间180～270min，术中出血量80～200mL，无围手术期严重并发症，术后血小板和白细胞计数均明显增加，随访1—6年，1例复发出血，予内镜下套扎曲张静脉控制出血，其余5例无症状。结论腹腔镜下巨脾切除联合选择性胃食管周围血管离断术安全可行，有微创优势，为小儿门静脉高压症并发出血和脾机能亢进的治疗提供了一个可选择的新术式。

Objective To report our preliminary experience with laparoscopic splenectomy and periesophagogastric devascularization by endoligature and its effectiveness for portal hypertention with bleeding and hypersplenism in children. Method Six patients with portal hypertension and severe hypersplenism included 5 males and 1 female who ranged in age from 8 to 17 years. All of them underwent laparoseopic splenectomy and selective perieardial devascularization by using silk endoligature combined a Harmonic scalpel. After massive splenectomy was performed, the periesophagogastric collateral vessels and perforating veins of the upper stomach and the lower esophagus were dissected. The stem of gastric coronary vein and paraesophageal collateral veins were remained in order to reserve portal blood flow toward azygous shunt. Results All the procedures were completed successfully under whole laparoscope. The operative time ranged from 180 to 270 minutes. Intraoperative blood loss was estimated to be from 80 to 200 mL. None of the patients required blood transfusion. There were no significant complications either intraoperatively or postoperatively. Postoperative platelet count and WBC count increased in individual patient. The data were statistically significant （ P = 0. 006,0. 002, respectively）. During a postoperative follow-up period of 1 to 6 years, one case with rebleeding was controlled by endoscopic variceal ligations, the others were asymptomatie with improved growth and hematology. Conclusion Laparoscopic massive splenectomy with selective periesophagogastric devaseularization is a feasible, effective, safe surgical procedures, and has all the benefits of minimally invasive surgery. It offers a new alternative modality for portal hypertension with bleeding and hypersplenism in children.