背景:作为门静脉海绵样变(PVCT)的新兴护理标准,Meso-Rex旁路(MRB)是复杂和变化的。该研究旨在提出一种新的PVCT分类方法,以指导MRB操作。
方法:人口统计数据,肝外PVCT的范围,内脏侧血管重建术的手术方法,术中失血,操作时间,MRB前后内脏静脉压的变化,从19例患者的病历中回顾性提取术后并发症和MRB术后旁路血管的状况.
结果:患者的中位年龄(男性13岁,女性6岁)为32.5岁,而两名患者未成年。PVCT的原因可以总结如下:血栓形成倾向,如抗凝血酶III或蛋白C功能障碍;继发于腹部手术;继发于腹部感染或外伤性肠梗阻,和未知的原因。术中,中位手术时间为9.5h(7-13h),术中出血量为300mL(100-1,600mL)。10例使用自体血管,10例使用同种异体血管。血管吻合根据部位和途径分为以下类型:(T)型1-PV蒂型,T2-合流型,T3-主要内脏血管型;和T4-侧支内脏血管型。此外,MRB前后内脏静脉压从36cmH2O(28-44)降至24.5cmH2O(15-31)(P<0.01)。术后,一名患者伤口愈合延迟,两个发达的生化胰瘘,一个经历了淋巴渗漏,前者是由胰腺组织的热损伤引起的,后者通过在分离肠系膜上静脉的过程中切断肠系膜的淋巴管或切除局部淋巴结,其中一人因插入肠瘘而再次手术。术后增强CT扫描显示分流术患者的腹部静脉曲张有显著改善,术后1年随访,6例患者的CT增强扫描显示脾脏长轴减少≥2cm.
结论:MRB能有效降低PVCT患者的内脏静脉压。根据受累程度确定PVCT类型并选择个体化的内脏侧血运重建表现是可行的。
BACKGROUND: As an emerging standard of care for portal vein cavernous transformation (PVCT), Meso-Rex bypass (MRB) has been complicated and variated. The study aim was to propose a new classification of PVCT to guide MRB operations.
METHODS: Demographic data, the extent of extrahepatic PVCT, surgical methods for visceral side revascularization, intraoperative blood loss, operating time, changes in visceral venous pressure before and after MRB, postoperative complications and the condition of bypass vessels after MRB were extracted retrospectively from the medical records of 19 patients.
RESULTS: The median age of the patients (13 males and 6 females) was 32.5 years, while two patients were underage. Causes of PVCT can be summarized as follows: thrombophilia such as dysfunction of antithrombin III or proteins C; secondary to abdominal surgeries; secondary to abdominal infection or traumatic intestinal obstruction, and unknown causes. Intraoperatively, the median operation time was 9.5 h (7-13 h), and the intraoperative blood loss was 300 mL (100-1,600 mL). Ten cases used autologous blood vessels while 10 used allogeneic blood vessels. The vascular anastomosis was divided into the following types according to the site and approach: Type (T) 1-PV pedicel type, T2-confluence type, T3-major visceral vascular type; and T4-collateral visceral vascular type. Furthermore, the visceral venous pressure before and after MRB dropped significantly from 36 cmH2O (28-44) to 24.5 cmH2O (15-31) (P < 0.01). Postoperatively, one patient had delayed wound healing, two developed biochemical pancreatic fistulae, one experienced lymphatic leakage, the former caused by heat damage of the pancreatic tissues, the latter by cutting lymphatic vessels in the mesentery or removing the local lymph nodes during the process of separating the superior mesenteric vein, and one was re-operated on for an intervening intestinal fistulae. Postoperative enhanced CT scans revealed a significant improvement in abdominal varix in the patients with patent bypass, and at the 1-year postoperative follow-up, enhanced CT scans of six patients showed that the long axis of the spleen was reduced by ≥ 2 cm.
CONCLUSIONS: MRB can effectively reduce visceral venous pressure in patients with PVCT. It is feasible to determine the PVCT type according to the extent of involvement and to choose individualized visceral side revascularization performances.