内镜下精准曲张静脉断流术治疗儿童食管胃底静脉曲张的初步评价

Evaluations of endoscopic selective variceal devascularization of esophagogastric varices in children

目的:初步评价内镜下精准食管胃底静脉曲张断流术(endoscopic selective varices devascularization,ESVD)的可行性。方法:对明确诊断为门静脉海绵样变、门静脉高压所致食管胃底静脉曲张的4例患儿进行ESVD术。其中,男1例,女3例;年龄为(6.70±1.41)岁,范围为4~7岁。总结分析病例特点、术中硬化剂与组织胶用量、术后恢复情况。结果:门静脉主干直径为(8.25±2.63)mm,范围为6~11 mm;肝脏弹性指数为(7.57±3.63)kPa,范围为4.08~10.90 kPa;最低血红蛋白(hemoglobin,Hb)值为(59.25±8.50)g/L,范围为51~68 g/L。食管静脉曲张程度1例F1、2例F2、1例F3,胃底静脉曲张程度1例F1、3例F2;食管硬化剂用量为(11.0±2.0)ml,范围为10~14 ml;胃底组织胶用量为(6.5±4.1)ml,范围为3.5~12.5 ml。术后1周复查所有病例均可见迂曲静脉部分萎瘪,食管曲张静脉可见血栓形成,胃底可见排胶溃疡,未见再出血;术后1个月复查1例出现排胶溃疡周围曲张静脉渗血,予组织胶再次填充封堵,余3例食管曲张静脉萎瘪、胃底仅见排胶溃疡;术后6个月复查排胶溃疡基本愈合,无再出血病例。结论:ESVD术可在不开腹或腹腔镜手术的情况下,利用胃镜通过自然腔道对门静脉高压导致的食管胃底静脉曲张起到填充封堵断流的效果,可减少患儿出现上消化道出血等危及生命的风险。为Rex分流术后以及食管胃底静脉断流、脾切除术后再出血的患儿,提供了一条可行、有效的治疗途径。

Objective To evaluate the feasibility of endoscopic selective esophagogastric variceal devascularization(ESVD).Methods ESVD was performed for 4 children with esophagogastric varices caused by cavernous transformation of portal vein and portal hypertension.The clinical characteristics,intraoperative doses of sclerosing agent,tissue glue and postoperative recovery status were analyzed.Results There were 1 boy(25%)and 3 girls(75%)with an average age of(6.70±1.41)(4-7)years.The diameter of portal vein trunk was(8.25±2.63)(6-11)mm,hepatic elasticity(7.57±3.63)(4.08-10.9)kPa and the lowest Hb(59.25±8.50)(51-68)g/L.The extents of esophageal varices were F1(n=1),F2(n=2)and F3(n=1);gastric varices F1(n=1)and F2(n=3).The dose of esophageal sclerosing agent was(11.0±2.0)(10-14)ml and that of gastric tissue glue(6.5±4.1)(3.5-12.5)ml.At Week 1 postoperatively,all cases showed partial atrophy of circuitous veins,thrombosis of esophageal varices,glue ulcer in gastric fundus and no re-bleeding.One case showed bleeding of varicose veins around glue ulcer at 1 month postoperatively and tissue glue was re-applied.The remaining 3 cases hinted at wilting atrophy of esophageal varices and glue ulcers in gastric fundus.At 6 months after esophagogastric operation,ulcer healed basically without re-bleeding.Conclusions ESVD may be employed for plugging esophagogastric varices caused by portal hypertension without open surgery or endoscopy.It lowers the life-threatening risk of upper gastrointestinal bleeding in children.For rebleeding after REX shunting,esophagogastric venous devascularization and splenectomy are efficacious.