Zhang Jinshan,Li Long.Anticoagulant therapy of heparin plus plavix after Rex shunt for children with extrahepatic portal venous obstruction[J].Journal of Clinical Pediatric Surgery,,21():146-150.[doi:10.3760/cma.j.cn.101785-202102027-009]
Anticoagulant therapy of heparin plus plavix after Rex shunt for children with extrahepatic portal venous obstruction
- Keywords:
- Extrahepatic Portal Venous Obstruction; Surgical Procedures; Operative; Anticoagulants/TU; Heparin; Child
- Abstract:
- Objective To explore the effectiveness of heparin plus plavix anticoagulant therapy in improving the prognosis and shunt patency of Rex shunt.Methods From January 2010 to September 2019, 51 children with extrahepatic portal venous obstruction (EHPVO) underwent portal cavernoma-Rex shunt with an interposition of grafted portal vessel.They were divided into two groups of anticoagulant and non-anticoagulant.There were 32 boys and 19 girls with a median operative age of 5.3(2.1-17.8) years.Twelve children in anticoagulation group received heparin plus plavix after Rex shunt while 39 in non-anticoagulation group had no anticoagulation.The follow-up period was over 1 year after Rex shunt.Incidence of postoperative rebleeding, initial time of postoperative rebleeding, postoperative stenotic or thrombotic rate of bypass vein, remission rate of postoperative hypersplenism, remission rate of postoperative esophagogastric varices and hepatopetal blood flow of bypass vein were compared between two groups.Results Eight cases in non-anticoagulant group suffered from postoperative rebleeding(e.g.hematemesis & black stool, etc).Average initial time of rebleeding was 12(1-24) months.There were thrombosis (n=6) and anastomotic stenosis(n=2)of bypass vein.In anticoagulant group, 10/11 cases of preoperative hypersplenism improved with a hypersplenism remission rate of 91%.In non-anticoagulant group, 11/19 cases of preoperative hypersplenism became relieved with a hypersplenism remission rate of 58%.No significant inter-group difference existed in hypersplenism remission rate(P=0.100).However, 3 patients without preoperative hypersplenism in non-anticoagulant group developed hypersplenism after shunt.In anticoagulant group, 1/3 cases with preoperative esophagogastric varices varices improved with a remission rate of 33%.In non-anticoagulant group, 5/11 cases with preoperative esophagogastric became with a remission rate of 46%.No significant difference existed in remission rate of esophagogastric varices(P=1.000).Blood flow of bypass vein was measured by ultrasound at 1 year post-operation.Based upon the formula:bypass venous flow index (BVFI)=flow volume of bypass vein (FV)/standard portal venous flow (SPVF), BVFI was calculated.BVFI of anticoagulant group was significantly higher than that of non-anticoagulant group[(5.71±5.89) vs.(1.1±1.52), P=0.003].Conclusion Anticoagulant therapy of heparin plus plavix plays an important role in the treatment of Rex shunt.It reduces postoperative rebleeding rate and maintains the patency of bypass vein.
References:
[1] de Ville de Goyet J,Clapuyt P,Otte JB.Extrahilar mesenterico-left portal shunt to relieve extrahepatic portal hypertension after partial liver transplant[J].Transplantation,1992,53(1):231-232.
[2] Poddar U,Borkar V.Management of extra hepatic portal venous obstruction (EHPVO):current strategies[J].Trop Gastroenterol,2011,32(2):94-102.
[3] Zhang JS,Li L,Cheng W.The optimal procedure of modified Rex shunt for the treatment of extrahepatic portal hypertension in children[J].J Vasc Surg Venous Lymphat Disord,2017,5(6):805-809.DOI:10.1016/j.jvsv.2017.02.011.
[4] Krebs-Schmitt D,Briem-Richter A,Grabhorn E,et al.Effectiveness of Rex shunt in children with portal hypertension following liver transplantation or with primary portal hypertension[J].Pediatr Transplant,2009,13(5):540-544.DOI:10.1111/j.1399-3046.2008.01109.x.
[5] Sharif K,McKiernan P,de Ville de Goyet J.Mesoportal bypass for extrahepatic portal vein obstruction in children:close to a cure for most![J]J Pediatr Surg,2010,45(1):272-276.DOI:10.1016/j.jpedsurg.2009.08.019.
[6] Luoto T,Pakarinen M,Mattila I,et al.Mesoportal bypass using a constructed saphenous vein graft for extrahepatic portal vein obstruction-technique,feasibility,and outcomes[J].J Pediatr Surg,2012,47(4):688-693.DOI:10.1016/j.jpedsurg.2011.10.065.
[7] Bhat R,Lautz TB,Superina RA,et al.Perioperative strategies and thrombophilia in children with extrahepatic portal vein obstruction undergoing the meso-Rex bypass[J].J Gastrointest Surg,2013,17(5):949-955.DOI:10.1007/s11605-013-2155-z.
[8] Guérin F,Bidault V,Gonzales E,et al.Meso-Rex bypass for extrahepatic portal vein obstruction in children[J].Br J Surg,2013,100(12):1606-1613.DOI:10.1002/bjs.9287.
[9] Ruan Z,Wu M,Shao C,et al.Effects of Rex-bypass shunt on the cavernous transformation of the portal vein in children:evaluation by the color Doppler ultrasonography[J].Insights Imaging,2020,11(1):4.DOI:10.1186/s13244-019-0815-6.
[10] 张金山,李龙,刘树立,等.小儿肝外门静脉高压Rex术后门静脉高压复发的临床分析[J].中华小儿外科杂志,2015,36(12):894-897.DOI:10.3760/cma.j.issn.0253-3006.2015.12.004. Zhang JS,Li L,Liu SL,et al.Etiology and treatment for recurrent portal hypertension after Rex shunting in children[J].Chin J Pediatr Surg,2015,36(12):894-897.DOI:10.3760/cma.j.issn.0253-3006.2015.12.004.
[11] 张金山,李龙,李颀,等.血管间置移植、门静脉主干-[KG-0.3mm]门静脉肝内左支分流术在治疗小儿肝外门静脉高压中的应用[J].中华小儿外科杂志,2016,37(9):682-686.DOI:10.3760/cma.j.issn.0253-3006.2016.09.010. Zhang JS,Li L,Li Q,et al.Managing extra-hepatic portal obstruction through extra-hepatic portal vein-left intrahepatic portal shunting with interposition of bypass vein in children[J].Chin J Pediatr Surg,2016,37(9):682-686.DOI:10.3760/cma.j.issn.0253-3006.2016.09.010.
[12] Kagimoto S,Fujitsuka S,Kinoshita K,et al.Study to establish normal values for portal vein blood flow in children using a duplex ultrasound system[J].Acta Paediatr Jpn,1991,33(6):693-698.DOI:10.1111/j.1442-200x.1991.tb02592.x.
[13] Ate? O,Hakgüder G,Olguner M,et al.Mesenterico left portal bypass for variceal bleeding owing to extrahepatic portal hypertension caused by portal vein thrombosis[J].J Pediatr Surg,2006,41(7):1259-1263.DOI:10.1016/j.jpedsurg.2006.03.043.
[14] Dasgupta R,Roberts E,Superina RA,et al.Effectiveness of Rex shunt in the treatment of portal hypertension[J].J Pediatr Surg,2006,41(1):108-112.DOI:10.1016/j.jpedsurg.2005.10.059.
[15] Gibelli NE,Tannuri AC,Pinho-Apezzato mL,et al.Extrahepatic portal vein thrombosis after umbilical catheterization:is it a good choice for Rex shunt?[J].J Pediatr Surg,2011,46(1):214-216.DOI:10.1016/j.jpedsurg.2010.09.091.
[16] Kitchens CS,Weidner MH,Lottenberg R.Chronic oral anticoagulant therapy for extrahepatic visceral thrombosis is safe[J].J Thromb Thrombolysis,2007,23(3):223-228.DOI:10.1007/s11239-006-9017-4.
[17] Silva-Junior G,Turon F,Hernandez-Gea V,et al.Unexpected disappearance of portal cavernoma on long-term anticoagulation[J].J Hepatol,2014,61(2):446-448.DOI:10.1016/j.jhep.2014.04.002.
[18] Khanna R,Sarin SK.Non-cirrhotic portal hypertension-diagnosis and management[J].J Hepatol,2014,60(2):421-441.DOI:10.1016/j.jhep.2013.08.013.
[19] Davenport M,Heaton N,Superina R.Surgery of the liver,bile ducts and pancreas in children,3rd edition[M].London:CRC Press,2017:297-306.
[20] 张金山,李龙.改良Rex手术治疗小儿肝外门静脉高压的疗效及最佳方法探讨[J].中华小儿外科杂志,2017,38(8):585-590.DOI:10.3760/cma.j.issn.0253-3006.2017.08.007. Zhang JS,Li L.Optimal procedure of modified Rex shunt for extrahepatic portal hypertension in children[J].Chin J Pediatr Surg,2017,38(8):585-590.DOI:10.3760/cma.j.issn.0253-3006.2017.08.007.
[21] Chin AC,Thow F,Superina RA.Previous portal hypertension surgery negatively affects results of mesenteric to left portal vein bypass[J].J Pediatr Surg,2008,43(1):114-119.DOI:10.1016/j.jpedsurg.2007.09.032.
[22] Gyoten K,Mizuno S,Kato H,et al.A novel predictor of posttransplant portal hypertension in adult-to-adult living donor liver transplantation:increased estimated spleen/graft volume ratio[J].Transplantation,2016,100(10):2138-2145.DOI:10.1097/TP.0000000000001370.
[23] Iwakiri Y.Pathophysiology of portal hypertension[J].Clin Liver Dis,2014,18(2):281-291.DOI:10.1016/j.cld.2013.12.001.
Memo
收稿日期:2021-02-20。
基金项目:国家自然科学基金（81770595、82170679）；首都卫生发展科研专项（首发2020-1-2101）
通讯作者:张金山,Email:zjs851@163.com