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,2022,21(02):146-150.[doi:10.3760/cma.j.cn.101785-202102027-009]
肝素联合波立维抗凝方案在Rex手术治疗小儿肝外门静脉梗阻中的应用及疗效分析
- Title:
- 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
- 摘要:
- 目的 探讨肝素联合波立维抗凝治疗方案对改善Rex手术预后和分流血管通畅性的效果。方法 以2010年1月至2019年9月首都儿科研究所收治的51例肝外门静脉梗阻（extra-hepatic portal venous obstruction，EHPVO）患儿为研究对象，其中男32例，女19例；51例均接受门静脉系统静脉间置、门静脉主干-门静脉左支分流术治疗。手术时年龄2.1~17.8岁，中位年龄5.3岁。根据Rex术后是否抗凝将所有患儿分为两组：抗凝组和未抗凝组。其中抗凝组12例，术后采用肝素联合波立维抗凝治疗方案；未抗凝组39例，术后未采取任何抗凝治疗。51例均随访1年以上，对比两组再出血发生率、再出血首发时间、分流血管狭窄或血栓形成率、术后脾功能亢进缓解比例、术后食管胃底静脉曲张缓解比例和分流血管入肝血流量的差异。结果 51例中，8例术后出现呕血、黑便等上消化道出血表现，首次出现上消化道出血的时间为术后1~24个月（平均12个月），其中6例为分流血管血栓形成，2例为分流血管吻合口狭窄；以上8例复发病例均在未抗凝组。抗凝组术前存在脾功能亢进11例，术后脾功能亢进缓解10例，术后脾功能亢进缓解率为91%；未抗凝组术前存在脾功能亢进19例，术后脾功能亢进缓解11例，术后脾功能亢进缓解率为58%，两组差异无统计学意义（P=0.100）。但3例术前无脾功能亢进者术后出现脾功能亢进，均在未抗凝组。抗凝组3例术前食管胃底静脉曲张，1例术后缓解（缓解率为33%）；未抗凝组11例术前食管胃底静脉曲张，5例术后缓解（缓解率46%）；组间差异无统计学意义（P=1.000）。术后1年超声测量分流血管血流量，并根据公式计算分流血管血流指数（分流血管血流指数=分流血管血流量/标准门静脉血流量）。对比抗凝组与未抗凝组的分流血管血流指数发现，抗凝组分流血管血流指数显著高于未抗凝组，差异有统计学意义[（5.71±5.89）vs.（1.1±1.52），P=0.003]。结论 肝素联合波立维抗凝方案在Rex术后治疗中发挥着重要作用，能有效降低术后复发率，尤其在保持分流血管通畅方面具有显著作用。
- 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.
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备注/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