双介入术治疗肝硬化门静脉高压症的临床疗效观察

Effectiveness of the double interventional therapy for portal hypertension in liver cirrhosis

目的探讨双介入术治疗肝硬化门静脉高压性上消化道出血、脾功能亢进的临床应用价值及并发症的预防。方法对32例确诊为肝硬化门静脉高压合并上消化道出血、脾功能亢进的患者,在超声引导下经皮肝门脉穿刺成功后,将导管超选择插入胃冠状静脉,再经股动脉穿刺插管、超选插入脾动脉分支,混合应用真丝线段、无水乙醇、明胶海绵、不锈钢弹簧圈进行双介入栓塞(胃底-食管曲张静脉及部分脾脏栓塞)治疗。结果本组32例PTVE穿刺成功率为100%,一针穿刺成功率为66%,栓塞成功率100%;PSE栓塞面积控制在40%～70%;术后24 h～1周白细胞、血小板明显升高;术后1个月、6个月、1年、2年和3年累计再出血率分别为0%、3.1%、12.5%、25%和31.3%;复发出血原因分别为曲张静脉再破裂出血26.1%、门静脉高压性胃病56.5%、消化性溃疡17.4%;所有患者均有不同程度的发热、腹痛、恶心及呕吐等栓塞后综合征,经对症治疗后缓解、症状消失,未发生与手术相关的严重并发症。结论双介入术治疗门脉高压性上消化道出血、脾功能亢进疗效确切,该方法操作相对简单,侵袭性小,尤其适用于肝功能差难以耐受外科分流及断流手术的患者,具有临床推广应用价值。

Objective To assess the value of double interventional therapy for upper gastrointestinal bleeding and hypersplenism caused by portal hypertension. Methods 32 patients with upper gastrointestinal bleeding and hypersplenism due to portal hypertension in liver cirrhosis were enrolled in the study. Ultrasound-guided pereutaneous punctures of both the intrahepatie portal varices and femoral artery were performed on all patients. The catheters were inserted into the vena coronaria ventrieuli and branches of splenic artery selectively and then embolized using mixture of alcohol, gelatin sponge and metal coin. Results The overall success rate of percutaneous transhepatic variceal puncture was 100% with single puncture in 66% and the success rate of embolization wasl00%. Partial splenic artery embolization was performed involving 40%-70% of the vascular lumen. White blood cell and platelet counts increased significantly 24 hours and 1 week after embolization. The cumulative incidences of rebleeding were 0, 3.1%, 12.5%, 25% and 31.3% in the 1 month, 6 month, 1 year, 2 year and 3 year follow-up respectively. Causes of recurrent bleeding included varices rupture （26.1%）, portal hypertensive gastropathy （56.5%）, and peptic ulcer （17.4%）. All of the patients had various degrees of fever, abdominal pain, nausea and vomiting after embolization. These symptoms subsided without further complications. Conclusion The double interventional approach is useful in the treatment of upper digestive tract hemorrhage and hypersplenism from portal hypertension. The method is relatively simple with low invasiveness especially for patients with poor liver function who cannot tolerate surgical shunt and de-vascularization operation.