经颈静脉途径介入干预经颈静脉肝内门体静脉分流术分流后肝性脊髓病的临床疗效

Clinical effects of transjugular interventional stent-shunt therapy in hepatic myelopathy after transjugular intrahepatic portosystemic shunt

目的评价介入治疗经颈静脉肝内门体静脉分流术（TIPS）分流后肝性脊髓病的临床疗效。方法对TIPS治疗术后诊断明确的肝性脊髓病16例患者进行再次介入干预治疗，早期有4例患者进行分流道局部药物灌注治疗预后较差；而后12例改用分流道限流治疗部分病例预后良好。使用Barthel指数评估日常生活能力，Lovette六级分期评价肌力。采用配对t检验对比限流手术前后的肝功能指标和门静脉压力变化，重复测量的方差分析和LSD法对比手术前后不同时间点随访数据（血氨值、肌力分级、Barthel评分）。结果12例患者限流前后肝功能、门静脉压力变化无统计学意义；TIPS限流前血氨为（77．9±17．9）mmol／L，限流后1、3、6、12个月分别为（77．9±14．8）、（73．4±21．5）、（59．5±14．5）、（52．0±16．5）mmol／L，与限流前相比差异有统计学意义（F=6．45，P〈0．05），限流术后6、12个月血氨浓度明显下降。限流术前肌力分级2．1±0．7，术后1、3、6、12个月分别为2．3±0．8、3．1±1．0、3．2±1．1、2．8±0．9，与限流前相比差异有统计学意义（F=4．97，P〈0．05），术后3、6、12个月患者肌力分级评分明显升高。Barthel评分限流前（42．1±10．5）分，限流后3个月[（47．1±11．0）分]、6个月[（45．0±8．8）分]评分增加，差异有统计学意义（F=5．05，P〈0．05），日常生活能力较前有所改善。临床肝性脑病发作程度TIPS术后Ⅰ、Ⅱ、Ⅲ、Ⅳ期分别为3、6、2、1例，限流术后3和6个月别为7、3、1、0例和8、1、1、0例。药物治疗组2例6个月内死于肝功能衰竭，1例行肝移植治疗，1例失访。结论介入治疗尤其是支架内限流术可改善TIPS术后出现的肝性脊髓病临床症状。

Objective To observe the efficacy of transjugular interventional therapy for patients with hepatic myelopathy after transjugular intrahepatic portosystemic shunt （TIPS）. Methods Sixteen patients with hepatic myelopathy afte TIPS were treated with interventional therapy again. Four patients who were treated with drugs through shunt previously had poor prognosis, then the remaining 12 patients treated with current limited shunt had better prognosis, which were analyzed in this study. Activities of daily living were assessed by Barthel index, limb muscle strength scores were assessed by Lovette scoring system. The changes of liver function and portal vein pressure were analyzed by paired t-test, while other data such as serum ammonia level, Barthel index, Lovette scores before and after transjugular interventional therapy were compared by analysis of variance with repeated measurements. Results All the patients had no complication after operations. The liver function and portal vein pressure of 12 patients had no significan change before and after operation. Blood ammonia value were （ 77.9 ± 17.9 ） mmol/L after TIPS, （ 77.9 ± 14. 8 ）, （ 73.4 ± 21.5 ）, （59.5 ± 14. 5 ）, （ 52.0 ± 16. 5 ） mmol/L 1,3,6,12 months after current limited shunt. Compared withthat of preoperation（ F = 6.45 ,P 〈 0. 05 ）, it decreased significantly at the 6th and 12th month. Limb muscle strength scores were 2. 1 ±0. 7 before current limited shunt,2. 3 ±0. 8,3.1 ± 1.0,3.2 ± 1.1,2. 8 ±0. 9 1,3, 6,12 months after the operation. Compared with preoperation （ F = 4. 97, P 〈 0. 05 ）, muscle strength grading improved significantly at the 3rd, 6th and 12th month. Activities of daily living Barthel index were 42. 1 ± 10. 5 before current limited shunt,47.1 ± 11.0,45.0 ± 8.8 3,6 months after the operation. Compared with preoperation （F = 5.05,P 〈 0. 05 ）, activities of daily living had improvement. There were 3,6,2,1 cases of hepatic encephalopathy of Ⅰ,Ⅱ,Ⅲ,Ⅳstage after TIPS. Three months after current limited shunt there were 7,3,1,0 cases, while there were 8,1,1,0 cases 6 months after the operation. In other 4 patients treated with drugs,2 patients died of liver failure, one was lost to follow. Conclusions Interventional therapy can relieve symptoms of hepatic myelopathy. The operation is safe, effective, and helpful after TIPS treatment.