改良经颈静脉肝内门体静脉分流术治疗肝硬化门静脉高压症

Modified transjugular intrahepatic portosystemic shunt in the treatment of portal hypertension of livercirrhosis

目的探讨改良经颈静脉肝内门体静脉分流术（TIPS）治疗肝硬化门静脉高压及其并发症的安全性和有效性。方法收集2005年1月至2009年12月280例接受TIPS治疗的肝硬化门静脉高压症患者的临床资料。所有患者均接受肝脏增强CT和肝静脉-门静脉血管三维重建，分析肝静脉与门静脉的解剖关系，选择穿刺f1静脉分支的靶点，术中通过直接门静脉造影分析门静脉分支穿刺靶点、右肝静脉开口和门静脉分叉位置的分布状况，在判断操作安全性后，栓塞引起食管胃底静脉曲张的胃冠状静脉，植入金属支架。治疗前后计量数据的比较行配对t检验。患者临床资料参数与TIPS术后并发症和疗效的相关性分析行Mann-Whitney U或H检验。结果280例患者中278例TIPS操作成功，成功率为99．3％（278／280）；发生腹腔出血2例；发生穿刺胆管、胆囊、肝动脉、肝包膜者分别有10、5、8、18例，均未导致腹腔或胆管出血。278例手术成功者中，穿刺门静脉右支198例，穿刺门静脉左支80例，门静脉分支穿刺靶点均在正位造影所示门静脉分叉以远。近期止血率为100％。门静脉主干压力由TIPS术前的（46．5±3．4）cmH20（1cmH2O=0．098kPa）降至术后的（26．8±3．6）cmH2O，差异有统计学意义（t=56．044，P〈0．01）。术后12和24个月支架狭窄率分别为24．1%（67／278）和34．2％（95／278）。术后6和12个月的肝性脑病发生率分别为18．0％（50／278）和19．1％（53／278）。不同病因、性别、年龄、Child—Pugh分级、穿刺靶点位置的患者术前和术后门静脉压的差值、再出血发生率、肝性脑病发生率、支架狭窄发生率差异均无统计学意义（P均〉0．05）。结论改良TIPS治疗肝硬化门静脉高压及其并发症较为安全和有效。

Objective To assess the safety and efficacy of modified transjugular intrahepatic portosystemic shunt （TIPS） in the treatment of portal hypertension of liver cirrhosis. Methods From January 2005 to December 2009, the clinical data of 280 patients with liver cirrhosis accompanied with portal hypertension accepted TIPS treatments were collected. All the patients received liver enhanced computed tomography （CT） and hepatic blood vessel CT three dimensional reconstruction to analyze the anatomical relationship of hepatic vein and portal vein and select the puncture location of portal vein branches. During operation, the puncture location of portal vein branches, the opening of the right hepatic vein and the distribution of portal vein branches were analyzed through directly portal vein portography. After operation safety was assessed, gastric coronary vein which caused esophageal varices was embolismed and the metal stent was implanted. Paired t-test was performed for measured data comparison before and after treatment. Mann Whitney U or H test was used for correlation analysis between clinicaldata of patients and post-operation complication of TIPS and efficacy. Results Among 280 patients, TIPS operations of 278 were successfully performed and the success rate was 99. 3% （278/280）. Hemoperitoneum occurred in two cases. The case number of puncture in biliary tract, gallbladder, hepatic artery and liver capsule was 10, 5, 8 and 18, respectively, however no hemoperitoneum or bile duct hemorrhage was observed. Among 278 cases with successful operation, 198 were the right branch of portal vein puncture and 80 were the left branch puncture. By anteroposterior angiography, the location of portal vein puncture was beyond the portal vein bifurcation. Short-term hemostasis rate was 100 %. The pressure of portal vein decreased from （46.5±3.4） cmH20（1 mmH20=0.098 kPa） before TIPS to （26.8±3.6） cmH2O after TIPS and the difference was statistically significant （t= 56. 044, P〈0.01）. The postoperative stent stenosis incidence was 24. 1% （67/278） at the 12th month and 34.2% （95/278） at the 24th month. The postoperative hepatic encephalopathy rate was 18.0% （50/278） at the 6th month and 19.1% （53/278） at the 12th month. There were no differences in the gradient pressure of portal vein before and after TIPS, re-hemorrhage rate, hepatic encephalopathy and stent stenosis rate between patients of different etiology, gender, age, Child-Pugh classification and the puncture location （all P〉 0.05）. Conclusion The modified TIPS was safe and effective in the treatment of portal hypertension of liver cirrhosis and its complication.