儿童门静脉高压Rex手术后血管并发症分析

Experience of vascular complications after Meso-rex bypass for portal hypertension

目的探讨以颈内静脉(internal jugular vein,IJV)作为搭桥血管的Rex手术术后血管并发症的发生原因和预防策略。方法回顾性分析自2014年10月至2019年8月54例接受初次Rex手术(采用IJV作为搭桥血管)治疗肝前性门静脉高压患儿的临床资料。其中,男35例,女19例;中位年龄5岁(0.8~14岁)。观察其临床表现、脾大脾功能亢进及食管胃底静脉曲张恢复情况,应用Pearsonχ检验和Fisher精确检验,对手术前后脾长径、脾厚度、血小板计数及胃镜静脉曲张分级进行统计学分析。结果54例患儿中,无血管并发症47例患儿术后均无消化道出血,脾大脾功能亢进缓解或消失,患儿手术前、后血小板计数(108.49±100.98)×10^(9)/L和(171.54±92.22)×10^(9)/L比较,数值显著上升,差异有统计学意义(P<0.01);手术前、后脾长径[(133.93±32.91)mm和(111.89±35.21)mm]和脾厚度[(44.88±11.03)mm和(34.72±9.04)mm]比较,数值均有所缩小,差异均有统计学意义(P均<0.01);F_(2)-F_(3)食管静脉曲张比例由术前73.9%(20/23)降至术后13.0%(3/23)。术后出现血管并发症7例(13.0%),其中血管栓塞2例(3.7%),血管狭窄5例(9.3%)。术后出现血管栓塞2例分别表现为脾功能亢进无缓解和消化道出血,均再次行Rex手术,术后血管通畅。血管狭窄5例表现为脾大、脾功能亢进缓解不良或消化道出血,超声及CT检查可见吻合口直径<3 mm、流速增加3~4倍。其中,2例行球囊血管扩张成功;1例行球囊血管扩张后效果不佳而行血管支架置入,术后均血管通畅,症状缓解;余2例暂未接受治疗。结论IJV搭桥Rex手术效果良好,可以达到根治的手术目的。血管栓塞和吻合口狭窄是影响IJV搭桥Rex手术术后效果或导致手术失败的最主要原因。出现血管栓塞患儿需要再次手术治疗,吻合口狭窄患儿行血管介入治疗并可以获得良好效果。

Objective To explore the causes and preventions of postoperative vascular complications of Rex shunt using internal jugular vein as a bypass vessel.Methods Retrospective analysis was performed for clinical data of patients with prehepatic portal hypertension from October 2014 to August 2019.Fifty-four patients were included with internal jugular vein(IJV)as a bypass vessel.Clinical features,ultrasonic findings,laboratory tests and gastroscopic observations were examined.Results No postoperative gastrointestinal bleeding was detected in children without vascular complications.Hypersplenism became alleviated or disappeared.Platelet count(PLT)rose significantly than those preoperatively(108.49±100.98&171.54±92.22,P<0.01)while splenic diameter(133.93±32.91&111.89±35.21,P<0.01)and splenic thickness(44.88±11.03&34.72±9.04,P<0.01)decreased.There were vascular complications(n=7,13.0%),vascular embolization(n=2,3.7%)and anastomotic stenosis(n=5,9.3%).Two patients with postoperative vascular embolization showed no relief of hypersplenism and gastrointestinal bleeding.After a second Rex shunt,postoperative vessels remained patent.Patients with anastomotic stenosis presented with persistent hyperhypersplenism and splenomegaly or gastrointestinal bleeding.Ultrasound and CT revealed anastomotic diameter<3 mm and blood flow rate increased 3-4 folds.Balloon vasodilation was successful in 2 patients with stenosis and stent implantation was performed for one child with a poor efficacy after dilatation.Vessels were unobstructed and the symptoms relieved while the remaining 2 patients were non-treated.Conclusions The operation of internal jugular vein bypass Rex had excellent outcomes with a high success rate.Vascular occlusion and anastomotic stenosis are the most important factors affecting postoperative outcomes or leading to surgical failure.Patients with vascular occlusion require reoperation and anastomotic stenosis may respond well to dilatation.