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目的 探讨肠系膜上静脉门静脉左支分流术(mesenteric-to-left portal vein bypass,MLPVB又称Rex Shunt,RS手术)治疗小儿肝前型门静脉高压分流或断流术后复发出血可行性、安全性、有效性.方法 2008年12月至2013年6月共对15例肝前性门静脉高压分流、断流术后复发出血的患儿实施RS手术.本组男8例,女7例;平均年龄(76.9±31.9)个月.15例患儿均于本次入院前1～3年接受过分流或断流手术,其中接受分流术6例,断流术9例;患儿术后复发呕血、黑便,需输血维持血红蛋白,输血量平均(1 280.0±280.8)ml.15例患儿术前红细胞降低,5例白细胞、血小板计数降低;血生化检查肝功能正常;无肝性脑病表现.术前影像学检查门静脉左支直径平均为(1.9±1.3)mm,其中3例门静脉左支未显示,5例直径小于3mm.手术采用上腹肋缘下横切口,测定肠系膜上静脉压力,并行门静脉造影.分离矢状部肝组织,游离肝门静脉左支,穿刺测压并造影,确认门静脉左支通畅,阻断钳阻断并纵行劈开矢状部.根据门静脉造影及探查情况选择游离胃冠状静脉、或脾静脉.然后以6-0 Prolene线将胃冠状静脉、脾静脉与门静脉左支行端侧吻合.再次测定肠系膜上静脉压力,并行血管造影.术后随访6～60个月.结果 15例患儿均成功实施RS手术,平均手术时间(203.3±25.3)min,出血约20～50ml,分流完成后造影显示分流血管均通畅无狭窄.分流前门静脉压力平均为(40.6±6.6)cmH2O,分流后平均降(20.6±4.8)cmH2O,平均住院时间(6.5±1.7)d.随访期间,无复发呕血,B型超声等影像学检查提示分流血管通畅.本组术中造影显示,15例患儿门静脉左支直径平均为(4.5±1.0)mm,与术前影像检查比较,差异有统计学意义(P=0.000,t=-6.1);术后超声检查显示,门静脉左支直径为(6.0±0.7)mm,与术中造影时比较,差异有统计学意义(P=0.000).本组术后血生化肝功能及血常规检查均在正常参考值范围内.结论 分流、断流术后再行RS手术手术难度较大,操作复杂,风险较高,应慎重实施手术;同时术者需要具有丰富的肝脏手术经验及RS手术经验,以保证应用RS手术治疗肝外型门静脉高压分流、断流术后复发出血手术的安全、及获得良好效果.单中心初步显示手术安全,近期效果良好.“,”Objective To explore the effectiveness and safety of Rex shunt for recurrent bleeding in children with extrahepatic portal hypertension after portosystemic shunt or devascularization procedures.Methods From December 2008 to June 2013,15 patients of recurrent upper gastrointestinal bleeding underwent mesenteric-to-left portal vein bypass (MLPVB) at a mean time of 24.9 ± 6.8 (12-36) months after portosystemic shunt or devascularization procedures.There were 8 boys and 7 girls with a mean age of 76.9 ± 31.9 (36-144) months.The procedures were distal splenorenal shunt (n =6) and devascularization (n =9).Vascular conduits included splenic vein,right gastroepiploic vein,coronary veins and inferior mesenteric vein.The mean follow-up period was (30.5 ± 18.3) (4-30) months.Results All patients underwent MLPVB successfully.The mean operative duration was 203.3 ±25.3 (160-240) min and intraoperative bleeding volume 20-50 ml without a necessity for blood transfusion.Portal pressure decreased after Rex shunt.The postoperative course was uneventful in 15 patients with a mean hospitalization stay of (6.5 ± 1.7) (4-12) days.There was no recurrence of gastrointestinal bleeding.Platelet count and white blood cell count rose.No postoperative complications occurred during the follow-ups.Conclusions Rex shunt procedure should be performed cautiously.And it is feasible,safe and effective for recurrent bleeding in children with extrahepatic portal hypertension after portosystemic shunt or devascularization procedures.