TIPS及其分别联合CVO、门奇静脉断流术治疗门静脉高压症的疗效比较

Long-term results of TIPS, TIPS with CVO and combined TIPS and portal azygous disconnection for the treatment of portal hypertension

目的研究经颈内静脉肝内门体分流术（TIPS）、TIPS联合冠状静脉栓塞术（CVO）、TIPS联合门奇静脉断流术治疗门静脉高压症的临床疗效。方法回顾性分析1993年7月至2008年5月收治的358例门静脉高压症伴食管静脉曲张患者的临床资料，所有患者分为3组，分别为TIPS组（n=227）、TIPS联合CVO组（n=36）和TIPS联合门奇静脉断流术组（n=95）。观察3组患者在手术成功率、并发症发生率、近期和远期分流道通畅率、再出血率、肝性脑病发生率和病死率方面的情况，并应用统计学方法比较其差异。结果成功完成TIPS操作349例，成功率为97．5％，TIPS失败患者9例，占2．5％。术后1个月分流道的阻塞率、肝性脑病发生率、再出血率和病死率分别为2．5％、31．8％、4．7％和9．0％。其中，TIPS组患者的肝性脑病发生率和病死率均高于TIPS联合门奇静脉断流术组（P〈0．01）。急诊行TIPS85例，术后肝性脑病发生率和病死率分别为41．2％和24．7％。术后随访1～15年，平均（68．7±47．6）个月，随访率为79．6％。术后1、2年分流道通畅率分别为74．0％和48．1％，其中TIPS联合门奇静脉断流术组术后1年分流道通畅率显著高于TIPS组和TIPS联合CVO组（P〈0．01和P〈0．05）。TIPS联合门奇静脉断流术组术后再出血率低于TIPS组（P〈0．01），远期生存率高于TIPS组和TIPS联合CVO组（P〈0．01）。结论TIPS是治疗门静脉高压症伴食管静脉曲张出咖的有效方法．与CVO或断流术联合廊用可提高临床疗效。

Objective To analyze the long-term results of TIPS, TIPS with coronary vein occlusion （CVO） and combined TIPS and portal azygous disconnection for the treatment of portal hypertension and variceal bleedings. Methods Three hundreds and fifty-eight patients with portal hypertension were admitted because of variceal bleeding from July 1993 to May 2008. All patients were divided into 3 groups ：227 cases in group TIPS ,36 cases in TIPS and CVO group ,95 cases in combined TIPS and portal azygous disconnection group. The rates of successful operation, shunt patency, rebleeding, encephalopathy and survival were observed and compared by statistics methods. Results There were 349 cases （97. 5% ） underwent successful surgery and 9 cases with failure surgery. The rates of occluded shunts, eneephalopathy, rebleeding,and death in early periods were 2. 5% ,31.8% ,4.7% and 9.0% respectively. The rate of encephalopathy and death in group with TIPS were higher than in group with combined TIPS and portal azygous disconnection（P 〈 0. 01 ）. The rate of encephalopathy and death were 41.2% and 24.7% in 85 cases with emergency TIPS. During the follow-up 1-15 years,the rate of patency shunts in 12 and 24 months after operation was 74. 0% and 48. 1% respectively. The rate of 1-year patency shunts in group with combined TIPS and portal azygous disconnection was higher than in group with TIPS, TIPS and CVO （P 〈 0. 01 and P 〈 0. 05）. The rebleeding in group with TIPS was higher than in group with combined TIPS and portal azygous disconnection （ P 〈 0. 01 ）, and the survival rate in group with TIPS was lower than in group with TIPS and CVO, combined TIPS and portal azygous disconnection （ P 〈 0. 01 and P 〈 0. 01 ） .Conclusions TIPS is an efficient therapy for portal hypertension with CVO, combined TIPS and portal azygous disconnection can improve the results of TIPS for portal hypertension.