改良Rex手术治疗小儿肝外门静脉高压的疗效及最佳方法探讨

Optimal procedure of modified Rex shunt for extrahepatic portal hypertension in children

目的探讨改良Rex手术治疗小儿肝外门静脉高压的效果和预后，明确最佳Rex手术方法。方法2008年2月至2016年3月，101例门静脉海绵样变患儿于我院接受Rex手术治疗，其中48例接受胃冠状静脉门静脉左支分流术（CV-LPV），26例接受移植门静脉系统血管间置、门静脉主干-门静脉左支分流术（iPV-LPV），5例行保留脾脏的脾静脉近端-门静脉左支分流术（SV-LPV），6例接受血管间置的脾静脉-门静脉左支分流术（iSV-LPV），2例肠系膜下静脉-门静脉左支分流术（IMV-LPV），4例双冠状静脉-门静脉左支分流术（dCv-LI）V），4例胃右静脉4-1静脉左支分流术（RGV-LPV），4例胃网膜右静脉-门静脉左支分流术（RGEV-LPV），2例Roux-en-Y空肠支静脉-门静脉左支分流术（RYV-LPV）。比较不同术式的手术时间、术后门静脉压力、脾功能亢进缓解程度、术后住院时间、术后再出血率、分流血管直径的差异。结果101例患儿均成功接受Rex手术治疗。手术时间：CV-LPV明显高于iPV-LPV（P=0．036）；iSV-LPV明显高于CV-LPV、iPV-LPV、RGV-LPV、RGEV-LPV和RYV-LPV（P=0．024、P=0．001、P=0．039、P=0．039和P=0．145）。术后肠系膜上静脉压力：iSV-LPV明显高于iPV-LPV、dCV-LPV和RYV-LPV（P〈0．05）；RGEV-LPV明显高于iPV-LPV、SV-LPV、dCV-LPV和RYV-LPV（P〈0．05）。术后总体上消化道再出血发生率为18．8％，CV-LPV 22．9 0A，iPV-LPV 11．5％，SV-LPV 20．0％，iSV-LPV 0％，IMV-LPV 50．0％，dCV-LPV 25．0％，RGV-LPV 0％，RGEV-LPV 50．0％，RYV-LPV 0％，组间比较差异无统计学意义（P=0．420）。术后血小板：RGV-LPV明显高于CV-LPV、SV-LPV、iSV-LPV和dCV-LPV（P＜0．05）；iPV-LPV明显高于SV-LPV和iSV-LPV（P〈0．05）。各Rex手术方法间术后脾脏长度、厚度、术后住院时间、术后分流血管直径和流速、术后血HGB差异无统计学意义（P〉0．05）。结论改良Rex手术是治疗小儿肝外门静脉高压的有效方式，其中移植门静脉系统血管间置、门静脉主干-门静脉左支分流术是最佳改良Rex手术方法，应作为首选术式。

Objective To explore the outcomes of modified Rex shunt in the treatment of extra- hepatic portal hypertension in children. Methods From February 2008 to March 2016, 101 patients with extrahepatic portal hypertension underwent Rex shunting at our hospital. The procedures included gastric coronary vein-left portal vein shunt （CV-LPV, n = 48）, main portal vein-left portal vein shunt with interposition of portal vessels （iPV-LPV, n = 26）, proximal splenic vein-left portal vein shunt （SV-LPV,n= 5）, splenic vein-left portal vein with interposition of portal vessels （iSV-LPV,n = 6）, inferior mesenteric vein-left portal vein shunt （IMV-LPV, n = 2）, double gastric coronary vein-left portal vein bypass （dCV-LPV, n = 4）, right gastric vein-left portal vein bypass （RGV-LPV, n = 4）, right gastroepiploic vein-left portal vein bypass （RGEV-LPV, n = 4） and Roux-Y jejunal vein-left portal vein bypass （RYV-LPV, n = 2）. Operative duration, postoperative portal vein pressure, size of spleen, postoperative hospitalization stay, postoperative rebleeding rate, diameter and blood flow of bypass vein were compared among various Rex shunts. Results Rex shunt was successfully performed in 101 patients. Operative duration： CV-LPV was significantly higher than iPV-LPV （P = 0. 036）. iSV- LPV significantly higher than CV-LPV, iPV-LPV, RGV-LPV, RGEV-LPV and RYV-LPV （P = 0. 024, P = 0. 001, P = 0. 039, P = 0. 039 ＆ P = 0. 145）. Postoperative mesenteric venous pressure： iSV- LPV significantly was higher than iPV-LPV, dCV-LPV and RYV-LPV （P〈0. 05）; RGEV-LPV significantly higher than iPV-LPV, SV-LPV, dCV-LPV and RYV-LPV （P〈 0. 05）. Postoperative rebleeding incidence was 18. 8% in all patients, CV-LPV was 22. 9%, iPV-LPV 11.5%, SV-LPV 20. 0%,iSV-LPV 0%,IMV-LPV 50. 0%, dCV-LPV 25.0%, RGV-LPV 0% RGEV-LPV 50. 0% and RYV-LPV 0%. No significant difference existed in postoperative rebleeding incidence among various Rex shunt groups （P = 0. 420）. Postoperative platelet： RGV-LPV was significantly higher than CV- LPV, SV-LPV, iSV-LPV and dCV-LPV （P〈0. 05） ; iPV-LPV significantly higher than SV-LPV and iSV-LPV （P〈0. 05）. No significant differences existed in length or thickness of spleen, postoperative hospitalization stay, postoperative bypass venous diameter ＆ blood flow velocity or postoperative blood hemoglobin among various Rex shunt groups （P 〉 0. 05）. Conclusions Modified Rex shunts are efficacious for extrahepatic portal hypertension in childrerL And iPV-LPV is a preferred procedure of Rex shunt.