经颈静脉肝内门腔静脉分流术治疗肝癌合并门静脉高压的临床研究

Clinical study on transjugular intrahepatic portosystemic shunt in treatment of portal hypertension of patients with hepatocellular carcinoma

目的探讨经颈静脉肝内门腔静脉分流术（TIPS）治疗肝癌合并门静脉高压的有效性、安全性和临床价值。方法收集肝癌合并门静脉高压患者95例，其中63例行TIPS治疗（TIPS组），观察术后情况并随访生存期资料，其余32例（对照组）行内科支持治疗，随访生存期资料。评估TIPS组术后情况、术后肝性脑病、再出血、死亡原因等。行Kaplan-Meier生存分析比较两组中位生存时间，分析Child—Pugh分级及终末期肝病评估模式（MELD）评分与术后生存时间的关系。结果TIPS组术后门静脉压力梯度平均降低13．6cmH2O（1cmH2O=0．098kPa），术后6个月肝性脑病和再出血的累积发生率分别为20．6％和26．3％，截至随访结束死亡56例，其中最终死于门静脉高压破裂出血者12例。TIPS组中位生存期较对照组延长。TIPS组中MELD评分≤13分者中位生存时间大于评分〉13分者（χ2=4．71，P=0．03），Child-Pugh分级A到C级中位生存时间依次缩短（χ2=15．6，P=0．00）。结论TIPS是治疗肝癌合并门静脉高压及其并发症安全有效的方法，应根据术前肝功能状况选择手术患者。

Objective To evaluate the therapeutic efficacy and safety of transjugular intrahepatic portosystemie shunt （TIPS） for the treatment of portal hypertension of patients with hepatocellular carcinoma. Methods Ninety-five portal hypertension patients with hepatic carcinoma were enrolled. TIPS was performed in 63 patients and the other 32 patients received support medical care. The data referred to survival time of the 95 patients after treatment was collected by follow-up visit. The informations about success rate of TIPS, hepatic encephalopathy,rebleeding and causes of death were assessed. The Kaplan-Meier method was used to compare the survival time between two groups. The association of survival time with Child-Pugh classification and model for end-stage River disease （MELD） score was analyzed. Results The success rate of TIPS was 97. 8% with reduction of mean portal vein pressure of 13.6 cmH2O （1 cmH2O=0. 098 kPa）. The incidence of hepatic encephalopathy was 20. 6% and rebleeding was 26. 3% six months after TIPS treatment. Fifty-six patients treated with TIPS died at the end of follow-up. Twelve of which were died of variceal bleeding complicated with portal hypertension. The median survival time of TIPS group （3. 67 months） was significantly longer than that of control group （1 month）. Moreover, the median survival time in patients with low MELD score （≤13） was significantly longer than that in those with high MELD score （〉13, x2=4.71 ,P=0. 03）. Whereas the median survival time was decreasing from Child-Pugh A to C（χ2 = 15. 6,P=0.00）. Conclusions TIPS is one of effective and safe therapeutic methods to control portal hypertension. However, liver function is an important factor for selection of TIPS.