Rex手术治疗胆总管囊肿术后门静脉海绵样变的应用研究  

Efficacy of Rex shunt for portal cavernoma after hepaticojejunostomy in children with choledochal cyst

作　　者：张金山[1,2] 李龙 Zhang Jinshan;Li Long(Department of General Surgery,Capital Institute of Pediatrics,Beijing,100020;Graduate School,Peking Union Medical College,Beijing 100730,China)

机构地区：[1]首都儿科研究所普外科,北京市100020 [2]北京协和医学院研究生院,北京市100730

出　　处：《临床小儿外科杂志》2019年第12期1004-1008,1013,共6页Journal of Clinical Pediatric Surgery

基　　金：国家自然科学基金(编号:81770595)

摘　　要：目的探讨Rex手术治疗胆总管囊肿术后肝外门静脉高压的方法和疗效。方法收集5例胆总管囊肿合并门静脉高压患儿的临床资料,其中男童2例;女童3例,年龄为1.7~10.2岁,平均年龄4.9岁。因“呕血、黑便”等上消化道出血症状于当地医院行超声和CT检查发现为门静脉海绵样变和脾脏肿大。患儿均有因“胆总管囊肿”开腹行胆总管囊肿根治术的腹部手术史,且术前超声和CT检查未见门静脉海绵样变和脾脏增大等门静脉高压表现。上消化道出血均发生在胆总管囊肿术后。5例患儿进行了Rex手术治疗;3例行胃左静脉-门静脉左支分流术,2例因胃左静脉管径较细(<5 mm)不适于行胃左静脉-门静脉左支分流术治疗,接受Roux-Y空肠肝支静脉-门静脉左支分流术治疗。术后定期随访复查。迄今随访2~100个月,平均随访46个月。结果所有患儿成功进行Rex手术治疗。手术时间180~375 min,平均219 min。术后住院时间7~12 d,平均8 d。1例Rex手术后因“分流血管闭锁”再次出现呕血和黑便等上消化道出血表现,行保守治疗,该患儿采用Roux-Y空肠肝支静脉-门静脉左支分流术治疗。其余4例术后超声检查显示分流血管通畅,无上消化道出血表现,白细胞、红细胞、血小板和血红蛋白较术前改善。3例术后超声检查显示脾脏较术前缩小,另外2例术后脾脏无缩小者为Roux-Y空肠肝支静脉-门静脉左支分流术治疗患儿。上消化道造影显示3例Rex手术后食管胃底静脉曲张表现消失,其余2例术后食管胃底静脉曲张者中1例为术后复发患儿,1例为术后随访2个月者。结论Rex手术治疗小儿胆总管囊肿根治术后门静脉海绵样变是一种安全可行的手术方法,其中胃左静脉-门静脉左支分流术是一种可靠的Rex手术方法。Objective To explore the efficacy and feasibility of Rex shunt for extrahepatic portal venous obstruction after hepaticojejunostomy in children with choledochal cyst.Methods From August 2010 to November 2018,five children of upper gastrointestinal bleeding or splenomegaly were diagnosed as portal cavernoma,and Rex shunt was performed.All of them underwent hepaticojejunostomy for choledochal cyst prior to an onset of portal hypertension.Three children underwent gastro-portal bypass while another two had Roux-Y jejunal vein-portal bypass due to an unsuitable left gastric vein.The mean follow-up period was 46(2-100)months.Results Rex shunt was successfully performed in all patients.The average operative duration was 219(180-375)min and the mean length of hospital stay 8(7-12)days.Postoperatively,one child undergoing Roux-Y jejunal vein-portal bypass suffered from rebleeding due to an atresia of bypass vein and conservative therapy was offered.The other four children had no rebleeding,bypass vein remained patent on postoperative ultrasound and the results of routine blood test(WBC,RBC,Plt&HGB)improved after Rex shunt.Splenic size decreased postoperatively(n=3)and postoperative splenic size expanded(n=2)undergoing Roux-Y jejunal vein-portal bypass.No esophageal varices occurred in three children after Rex shunt.One child of postoperative esophageal varices developed rebleeding and another one of esophageal varices was merely followed-up for 2 months.Conclusion Rex shunt is both safe and feasible for extra-hepatic portal hypertension after hepaticojejunostomy in children with choledochal cyst.And gastro-portal bypass is a reliable Rex shunt.

关 键 词：Rex手术 胆总管囊肿 门静脉海绵样变 肝管空肠吻合术 肝外门脉高压 儿童 

分 类 号：R726[医药卫生—儿科] R575.7[医药卫生—临床医学]