经颈静脉肝内门腔静脉内支架分流术(TIPSS)治疗门脉高压症(附215例分析)

Review of the transjugular inirahepatic portosystemic stent shunt (Tipss) in treatment of portal hypertension in the past 12 years (analysis of 215 cases)

目的评估经颈静脉肝内门腔静脉内支架分流术(transjugular intrahepatic portosystemic stent shunt,TIPSS)在治疗门静脉高压症的作用和地位。方法总结分析215例门静脉高压症接受TIPSS治疗患者临床资料。结果术前曾行外科脾切除加断流术12例,行食道曲张静脉套扎、硬化58例。手术成功率90.70%(195/215),TIPSS188例,经肝段下腔静脉穿刺门脉建立TIPSS分流(TCTIPSS)7例。术前平均门静脉压力由(3.65±0.70)kPa降至术后的(2.15±0.68)kPa(P<0.01)。3例出血患者急诊行TIPSS治疗均成功止血,顽固性胸腹水缓解率80%(4/5)。一过性肝性脑病(HE)占35.38%(69/195),复诊者支架狭窄22例,其中再出血住院7例,有8例分流道再成形。术后5年生存率占31.27%(61/195),存活超过10年1例,接近9年3例。与操作相关的死亡2例,均系穿破肝包膜并肝素使用后致腹腔出血不止。近期(3个月内)死亡10例,占5.13%(原因包括穿破肝包膜2例,术后镇静剂安定使用2例,利尿剂未减量致电解质严重紊乱1例,术前顽固性胸腹水术后肝功能衰竭5例)。死亡病人中生存最长9年1例(死于结肠癌术后),有3例(存活6年、7年、8年)分别死于干扰素使用后肝功能衰竭和旅游性腹泻。结论TIPSS治疗门静脉高压症疗效肯定,并发症少,防治出血更符合卫生经济学。术后应禁用镇静剂,慎用利尿剂,门静脉穿刺困难者即刻不抗凝须小心。

[Objective] To evaluate the effect of transjugular intrahepatic portosystemic stent shunt （TIPSS） in the treatment of portal hypertension. [Methods] 215 cases of portal hypertension accepting TIPSS were summarized and analysed. [Results] Before TIPSS, 12 cases underwent surgical splenectomy and variceal transection, and 58 cases underwent band ligation and seleretherapy of the varices. The successful rate was 90.70% （195/215）. 188 cases underwent TIPSS, and 7 cases underwent transcaval transjugular intrahepatic portosystemic stent shunt （TCTIPSS）. Mean portal pressure dropped from （3.65±0.70） kPa to （2.15±0.68） kPa after operation （P 〈0.01）. The successful rate of emergency hemostasis was 100%, and the relief rate of refractory ascites was 80% （4/5）. The rate of temporary hepatic encephalopathy was 35.38% （69/195）. 22 cases presented with stent stenosis in the follow-up, 7 cases presented with rebleeding and rehospitalization, and 8 cases presented with angioplasty. The survival rate in 5 years was 31.27% （61/195）. There were 1 case surviving for more than 10 years and 3 cases for about 9 years after TIPSS. 2 died cases associated with the manipulation were due to puncturing and breaking hepatic capsule as well as the injection of heparinate causing abdominal bleeding. The early mortality （died within 3 months） was 5.13% （10/195）, including 2 cases of hepatic capsule injury, 2 cases of sedative use, 1 case of diuretics causing severe electrolyte confusion, and 5 cases of accompanying refractory ascites and hepatic dysfunction after operation. The longest survival time in died cases was over 9 years and this patient died of the postoperation of colonic cancer. There were 3 cases （surviving for 6, 7, and 8 years） died of hepatic dysfunction after the use of interferon and traveling diarrhea respectively. [Conclusion] TIPSS is available and satisfactory in the treatment of portal hypertension with fewer complications, and it is more appropriate to sanitation economics. The data suggested that sedatives should be forbidden, diuretics should be applied carefully, and instant anti-coagulation should be careful for patients accompanying ditticulty in the puncture of the portal vein during TIPSS.