经颈静脉途径肝内门体分流术的临床应用

A Study of Clinical Application by Transjugular Intrahepatic Portosystemic Stent Shunts(TIPSS)

报告120例 TIPSS 治疗的中期随访结果,探讨影响疗效的因素。120例全部有中度以上食管-胃底静脉曲张。术后随访方法有 US、内镜或/和食管钡餐、肝功能及血管造影等。结果:111例成功,技术成功率为92.5%。建立分流后门脉压力从术前的40.5±4.5cmH_2O(1cmH_2O=0.098kPa)降至23.5±3.5cmH_2O 术后2周 Doppler 超声显示分流道流速峰值为106±68cm/s,脾、门静脉血流速度较术前增加50%以上。术后4～6个月内死亡9例。分流道狭窄或闭塞22例,占随访病例的25.0%。再通成功12例。随访病例的通畅率:首次通畅率为75.0%,第二次处理后的累计通畅率为88.5%。结论:TIPSS 的技术成功率高,降低门脉压及即刻止血可靠,但术后分流道狭窄、阻塞的发生率较高,以 Z 型支架组尤为突出,因而强调术后应定期随访,以及早发现、处理分流道异常。TIPSS 后肝功能衰竭主要见于 Child C 级患者。

We retrospectively analyzed 120 cases of TIPSS focused on the mid-term results and its effective factors of the procedure.93 patient were male,27 female with mean age of 46 years(range,18～75 years).106 cases had recurrent bleeding for gastro esophageal varices.All patients had more than moderate gastroesophageal varices.The fol- low up results by us,endoscopy or/and esophageal barium examination,liver functin tests and angiogrophy down showed that—shunts were in 111 of 120 patients,no death occurred during the procedure.Portal pressure was reduced from 40.5±4.5 cmH_2O(1cmH_2O=0. 098kPa)to 23.5±3.5H_2O after shunting.Doppler US revealed tha the maximum blood flow velocity in the main portal vein increased from 14.0±4.5cm/sec to 46.5±14.5/sec. Two patients died of uncontrollable massive variceal bleeding within 2 hours after the TIPSS,9 died at 4 to 6 months after the procedure(due to hapatic function failure in 4,re- current bleeding 2,and unrelated to the procedures 3),The mean follow-up time in the suc- cessful cases was 16 months(range,4～27 months).Shunt stenosis and occlusion were found in 22 patients,12 of them were successfully treated with re-dilatation and placement of an another stent.The shunt patency was determined by corlor Doppler US in the remain- ing patients and no rebleeding occurred.The overall primary patency was 75.0%.Angio- plasty and stent placement in the stenotic shunt resulted in a secondary patency of 88.5%. The results suggested the immediate portal decompression could be achived in all successful cases but the incidence of shunt stenosis and occlusion was high,especially in Z stent group. Careful follow up is extremely important to identify shunt stenosis or occlusion for prompt correction.Liver failure in Child class C patients was a major constributor to the death fol- lowing TIPSS.