楔入法经肝静脉逆行门静脉造影辅助儿童肝外门静脉梗阻手术决策制定  

Application of wedged hepatic venous portography for assisting surgical decision-making in children with extrahepatic portal vein obstruction

作　　者：王增萌[1] 李志强[2] 彭春辉[1] 刘晖[3] 杨阳[3] 丁楠[2] 吴东阳[1] 王凯[1] 陈亚军[1] Wang Zengmeng;Li Zhiqiang;Peng Chunhui;Liu Hui;Yang Yang;Ding Nan;Wu Dongyang;Wang Kai;Chen Yajun(Department of General Surgery,Affiliated Beijing Children's Hospital,Capital Medical University,National Center for Children's Health,Beijing 100045,China;DepartmentⅡof Cardiac Surgery,Affiliated Beijing Children's Hospital,Capital Medical University,National Center for Children's Health,Beijing 100045,China;Department of Cardiology,Affiliated Beijing Children's Hospital,Capital Medical University,National Center for Children's Health,Beijing 100045,China)

机构地区：[1]国家儿童医学中心,首都医科大学附属北京儿童医院普外科,北京100045 [2]国家儿童医学中心,首都医科大学附属北京儿童医院心外二科,北京100045 [3]国家儿童医学中心,首都医科大学附属北京儿童医院心脏内科,北京100045

出　　处：《中华小儿外科杂志》2023年第6期493-500,共8页Chinese Journal of Pediatric Surgery

摘　　要：目的总结楔入法经肝静脉逆行门静脉造影辅助儿童肝外门静脉梗阻手术决策制定的临床经验。方法纳入2021年1月至2022年12月首都医科大学附属北京儿童医院单组收治的肝外门静脉梗阻儿童17例,其中男8例,女9例;中位(四分位数间距)入院年龄为83.2(50.9~116.2)个月。均行楔入法经肝静脉逆行门静脉造影及增强CT检查。总结楔入法经肝静脉逆行门静脉造影的操作经验、造影判读分类结果,与增强CT影像结果进行比较,结合手术操作结局,明确楔入法经肝静脉逆行门静脉造影用于辅助儿童肝外门静脉梗阻手术决策制定的临床应用价值。结果根据楔入法经肝静脉逆行门静脉造影形态,按照Bertocchini分类方法,17例患儿中,A型8例,B型3例,C型1例,D型3例,E型2例。楔入法逆行门静脉造影较增强CT显示Rex血管、肝内门静脉通畅情况和解剖走行更清晰、准确。A、B、C型拟行Meso-Rex搭桥术,术中均可解剖出Rex血管,最终Meso-Rex搭桥术成功A型7例,B型3例,C型0例。D型1例、E型1例术中探查Rex血管闭塞,分别行远端脾肾静脉分流+后期肝移植、脾切除+断流术。其余2例D型及1例E型病例未探查Rex血管,分别行肝移植1例,胃镜下食管胃底静脉曲张套扎及硬化治疗2例。结论在肝外门静脉梗阻患儿中,楔入法经肝静脉逆行门静脉造影能显示Rex血管条件、肝内门静脉系统通畅情况及解剖走行清晰、准确,可有效辅助手术方式选择;A、B、C型首选Meso-Rex搭桥术。Objective To summarize clinical experiences of wedged hepatic venous portography assisting surgical decision-making in children with extrahepatic portal vein obstruction.Methods A total of 17 children with extrahepatic portal vein obstruction admitted into our group was consecutively recruited from January,2021 to December,2022.Enhanced computed tomography(CT)and wedged hepatic venous portography were performed.Clinical experiences of managing portography and its categorical imaging results were summarized and compared with CT results.In conjunctions with surgical findings,the value of applying wedged hepatic venous portography for assisting surgical decision-making.Results There were 8 boys and 9 girls with a median(interquartile range)admission age of 83.2(50.9-116.2)months.According to the Bertocchini classification,the results of wedged hepatic venous portography were categorized as type A(n=8),type B(n=3),type C(n=1),type D(n=3)and type E(n=2).Compared with enhanced CT,wedged hepatic venous portograghy was more distinct and precise in visualizing Rex recess,patency of intrahepatic portal vein and its anatomical road map.Children of type A/B/C underwent Meso-Rex bypass and Rex recess remained patent with successful Meso-Rex bypass 7/8 cases in type A,3/3 cases in type B and 0/1 case in type C.Obliterated Rex recess was confirmed in 1 type D child and 1 type E case underwent distal splenorenal shunt+secondary liver transplantation and splenectomy+devascularization.The remaining type D/E children were not surgically explored.One child underwent liver transplantation and two cases had endoscopic sclerosis and band ligation.Conclusions Wedged hepatic venous portography may distinctly and precisely visualize Rex recess,patency of intrahepatic portal vein and its anatomical road map in type A/B/C children with extrahepatic portal vein obstruction.It can effectively assist surgical decision-making so that Meso-Rex bypass should become a first option.

关 键 词：门静脉造影术 肝外门静脉梗阻 Meso-Rex搭桥术 门静脉高压 儿童 

分 类 号：R726.5[医药卫生—儿科]