【作者】 张伟；

【导师】 刘树伟；

【作者基本信息】 山东大学 ， 人体解剖与组织胚胎学， 2014， 博士

【摘要】 研究背景门静脉海绵样变性(cavernous transformation of portal vein, CTPV)发生在儿童的一种罕见性疾病,目前为止,其发病原因还不十分清楚,患病儿童由于门脉主干阻塞,血流不畅,容易造成肝外门静脉高压,常常以上消化道出血就诊。近二十年来,肠系膜上静脉-门脉左支搭桥术(meso-Rex bypass,MRB)成为治疗该病的首选手术方法。该手术经典的方法是取自体颈内静脉作为分流血管；近年来,其他的自体血管例如：大隐静脉、脾静脉、胃左静脉及肠系膜下静脉也在手术中作为分流血管使用。1.研究目的探讨部分截取自体脾静脉为肠系膜上静脉-门脉左支搭桥术(meso-Rex bypass,MRB)分流血管的手术方法治疗儿童门静脉海绵样变,结合分析术前及术后临床资料来观察其对降低门静脉高压的作用,判断手术有效性。同时探讨彩色多普勒超声及多层螺旋CT在术前评估及术后随访中的作用。2.材料与方法将20例手术备选者进行术前彩色多普勒超声及多层螺旋CT检查,并与术中脐静脉造影结果对照,对符合手术要求的14例患儿行MRB手术。其中男10例,女4例,年龄5.5岁到14岁(8.7±2.5岁),平均体重为32.7±4.3kg,其中12例患者以上消化道间断性呕血、黑便、脾大就诊；2例为查体发现；10例患者合并脾亢,5例患者合并有黄疸表现；11例有硬化和(或)套扎、断流等各类手术史。所有术后患者随访12-48个月,平均26.6±12.7月。结果：彩色多普勒超声及螺旋CT腹部强化检查所有20例拟行脾静脉为分流血管的肠系膜上静脉-门脉左支搭(MRB)搭桥手术患者中,肝脏均未见占位征象,其中2例肠系膜上静脉非常纤细,不宜行MRB搭桥术,转行其他转流手术；有4例门静脉主干呈海绵样变,其左右支亦栓塞；行远端脾肾分流(Warren手术)；有3例患者在术前超声及CT腹部强化检查未发现正常的门脉左支,但是在术中通过脐静脉直接造影中发现门脉左支显示良好,因此共有14例患者成功进行了脾静脉MRB手术。在所有脾静脉MRB搭桥手术中,门静脉主干压力有术前的34.5±6.2cm H20降低到术后的17.5±4.3cm H20(P<0.01)；术后12个月通过分流血管的血流平均流速为29.3cm/s(25.6±8.2cm/s),门静脉主干的宽度由术前的13.5±0.4mm降低为术后的11.6±0.3mm,平均数白细胞数手术前后分别为5.9±1.7和8.9±2.4x109/L(P<0.01)；平均血小板数手术前后分别为63.5±13.6和160.2±28.1×109/L(P<0.01),血红蛋白由术前的86.2±20.6×109/L增加到术后的126.2±28.1×109/L(P<0.01)。随访至12个月和24个月,发现2例患者分流血管血栓阻塞,在本组研究中,以脾静脉为分流静脉的MRB血管分流术的通畅率为86%(12/14)。4、结论(1)彩色多普勒及螺旋CT腹部强化检查在以脾静脉为分流静脉的MRB血管分流术中是十分必须的,但是只直接脐静脉造影才手术的最终标准。(2)以脾静脉为分流静脉的MRB血管分流术中对于治疗门静脉海绵样变性引起的肝外性门静脉高压效果良好,且手术简便快捷并发症少,应该受到重视。1.研究目的探讨部分截取自体大隐静脉为肠系膜上静脉-门脉左支搭桥术(meso-Rex bypass,MRB)分流血管的手术方法治疗儿童门静脉海绵样变,结合分析术前及术后临床资料来观察其对降低门静脉高压的作用,判断手术有效性。2.材料与方法将8例手术备选者进行术前彩色多普勒超声及多层螺旋CT检查,并经过术中脐静脉造影结果显示门脉左支及囊部通畅其中男5例,女3例,年龄5..8岁到13.5岁(9.1±2.5岁),平均体重为34.5±3.6kg,其中8例患者均以上消化道间断性呕血、黑便、脾大就诊；6例患者已在外院行完全脾切除术。所有术后患者随访12-48个月,平均26.6±12.7月。3.结果：彩色多普勒超声及螺旋CT腹部强化检查所有8例拟行大隐静脉为分流血管的肠系膜上静脉-门脉左支搭(MRB)搭桥手术患者中,肝脏均未见占位征象,,门脉左支显示良好。所有8例患儿经脐静脉造影证实门脉左支及囊部通畅,所有8例患者成功进行了大隐静脉MRB手术。手术时间255-350分钟(平均295±25.5分)平均住院时间为15.6±2.3天,大隐静脉长度6.0-8.0cm(平均7.1±0.7cm)术后超声显示分流血管向肝血流良好。门静脉主干平均压力有术前的32.2±6.1cm H20降低到术后的19.5±4.6cm H20(P<0.05).患者术后恢复良好、平稳,抗凝血药物常规应用。随访时间长度为12-48个月,随访期内未见呕血及黑便。上消化道胃镜显示患病儿童食管胃底静脉曲张程度均有不同程度减轻(表1)。术后12个月通过分流血管中段的平均血流速度为15.6±4.2cm/s,门脉左支囊部血流速度由术前的15.7±3.6cm/s增加到术后的20.7±5.2cm/s (P<0.05);手术前后平均白细胞数分别为5.2±1.1和7.8±2.7×109/L(P<0.05)；平均血小板数分别为76..5±13.1和187.2±34.3×109/L(P<0.01),血红蛋白由术前的70.1±21.3×109/L增加到术后的106.3±20.5×109/L(P<0.05)。随访至6个月和12个月,彩色多普勒超声发现2例患者分流血管血栓阻塞,行保守治疗,择期行远端脾肾分流(Warren手术)；因此,在本组研究中,以大隐静脉为分流静脉的MRB手术的通畅率为75%(6/8)。4、结论大隐静脉在肠系膜上静脉-门脉左支分流术(Meso-Rex Bpass,MRB)中是非常有价值的桥血管,不但可以有效地缓解门脉高压,还可以使患儿的生理指标恢复正常。更多还原

【Abstract】 Background:Cavernous transformation of portal vein(CTPV) in children is a rare disorder in early childhood with unknown incidence and mostly unknown etiology. In children with CTPV, the hepatopedal flow of the mesenteric venous blood is hindered by an obstruction of the PV resulting in prehepatic portal hypertension。In the past decades Meso-Rex bypass is used to treat patients with clinically important cavernous transformation of portal vein(CTPV).Usually, an autologous left internal jugular vein graft is used usually to bypass the portal blood circulation from the superior mesenteric vein to the left portal vein. Other vascular conduits including the autogenous saphenous vein, splenic vein, right gastroepiploic vein, and inferiormesenteric vein were applied as shun vesssels.Purpose:Meso-Rex bypass (MRB)is increasingly used to treat chronic prehepatic portal hypertension secondary to extrahepatic portal vein thrombosis (PVT)or cavernous transformation of the portal vein (PVC), in children. Rather than using the internal jugular vein (the traditional venous graft), we used an autogenous splenic vein segment graft for the MRB.At the same time, the role of color Doppler ultrasound and multi-slice spiral CT were explored in the preoperative and follow-up postoperative assessment.Methods:Fourteen children had Meso-Rex bypass with portal hypertension of unknown etiology. Including Ten boys and four girls; mean8.7±2.5years; mean weight32.7±4.3kg.Eleven children had a history of recurrent upper gastrointestinal variceal bleeding and melena despite endoscopic sclerotherapy. Ten children had splenomegaly, and/or hypersplenism, Five children had jaundice.Left portal vein patency was verified with intraoperative direct portography through the umbilical vein in14patients. The splenic vein was harvested and anastomosed between the superior mesenteric vein and the umbilical portion of the left portal vein. All patients were followed for12-48months (mean,26.6±12.7months) and no patients were lost to follow-up.Results:Preoperative Doppler ultrasound imaging indicated that11patients had adequate intrahepatic portal veins for shunting, with no blood flow in the left portal vein in3patients. Left portal vein patency in14patients was verified with intraoperative direct portography, with successful MRB. Shunting was converted to a portosystemic shunt in the remaining4patients with thrombosed Rex recessus and left portal vein. Doppler ultrasound evaluation of the vein conduit revealed excellent flow postoperatively. During follow-up, The portal pressure gradient was measured intraoperatively and decreased from34.5±6.2cm H2O before bypass to17.5±4.3cm H2O after bypass (P<0.01), the mean leukocyte and platelet counts increased dramatically from5.9±1.7to8.9±2.4×109/L(P<0.01)and from63.5±13.6to160.2±28.1×109/L (P<0.01),mean hemoglobin increased from86.2±20.6×109/L to126.2±28.1×109/L (P<0.01) after shunting. The width of portal vein descended from13.5±0.4mm before shunt to11.6±0.3mm after bypass.Occlusion or narrowing occurred in2/14patients after discharge, and at12months in one patient and24months in another, the cumulative graft patency rate was86%(12/14).Conclusions:1. Splenic vein autografting can successfully resolve prehepatic portal hypertension inchildren in meso-Rex bypass. 2whether was the left portal branch, especially the left pockeo thrombosised is a decisive factor in bypass, but portal vein angiography is the gold standard.3. Color Doppler ultrasound and MSCT scanning has an important role in the cavernous diagnosis and preoperative assessment, for postoperative follow-up, color Doppler ultrasound is the preferred choice. Purpose:Meso-Rex bypass (MRB) is increasingly used to treat chronic prehepatic portal hypertension secondary to extrahepatic portal vein thrombosis (PVT)or cavernous transformation of the portal vein (PVC), in children. Rather than using the internal jugular vein (the traditional venous graft), we used an great saphenous vein segment graft for the MRB.,as the same time,preoperative and follow-up postoperative assessment.Methods:Eighteen children had Meso-Rex bypass with portal hypertension of unknown etiology.Including Five boys and three girls; mean9.1±2.5years; mean weight34.5±3.6kg.All children had a history of recurrent upper gastrointestinal variceal bleeding and melena despite endoscopic sclerotherapy. Six children had splenectomy.Left portal vein patency was verified with intraoperative direct portography through the umbilical vein in8patients. The great saphenous vein was harvested from the left thigh through a groin incision for use as a conduit for revascularization of the left portal vein. The harvested segments of the great saphenous vein were about10%longer than the estimated graft length. End-to-side anastomosis was performed first between the graft and the junction of the round ligament and left portal vein and then to the SMV using7-0Prolene sutures.All patients were followed for12±48months (mean,26.6±12.7months) and no patients were lost to follow-up.Results:The mean operative time was295minutes (range,255-350minutes), and the average hospital stay was14days (range,11-19days). The median length of the harvested saphenous vein was7.0cm (range,6.0-8.0cm), and the median diameter of the graft vein was0.41cm (range,0.38-0.45cm). The portal pressure gradient was measured intraoperatively and decreased from32±6cm H2O before bypass to19±4cm H2O after bypass (p<0.05). Doppler evaluation of the vessels upon completion of the anastomoses revealed excellent flow. Postoperative recovery was rapid and uneventful in seven patients. GI variceal bleeding recurred in one patient on the seventh postoperative day. Anticoagulant therapy was stopped, and the GI bleeding was successfully treated by endoscopic sclerotherapy. Patients who underwent the Rex shunt procedure were followed for6to36months postoperatively.Twelve months postoperatively, the median blood flow rate through the midgraft was14.3cm/s (mean±standard deviation,15.6±4.2cm/s) by Doppler US evaluation Although the left portal vein and its intrahepatic branches were hypoplastic during the preoperative Doppler evaluation, the mean blood flow velocity of the umbilical part of the left portal vein increased from15.7±3.6to20.7±5.2cm/s(p<0.05). All patients have undergone a postoperative upper gastrointestinal endoscopy.Endoscopic status has significantly improved in all cases after the operation.Residual varices were single,small or medium size,and pressure depressed. There has no recurrence of bleeding in any of the eight patients.Two patients underwent follow-up low dose computed tomography examination, which showed that the graft vein had good flow to the liver after the Rex shunt procedure.During the follow-up period, the mean leukocyte and platelet counts dramatically increased from5.2±1.1to7.8±2.7×109/L (p<0.05) and76.5±13.1to187.2±34.3×109/L (p<0.05), respectively. The hemoglobin increased from70.1±21.3×109/L to106.3±20.5×109/L (P<0.05). All biochemical parameters were within their reference ranges in all patients.(p<0.05).Conclusions: We have shown that construction of a great saphenous vein graft is a feasible and valuable alternative for mesoportal bypass in patients withCTPV.更多还原