经颈静脉肝内门体分流术联合胃冠状静脉栓塞术治疗肝硬化门静脉高压症上消化道出血中远期疗效评价

The mid-long-term clinical efficacy of transjugular intrahepatic portosystemic shunt combined with gastric coronary vein embolization for portal hypertension complicated by upper gastrointestinal bleeding

目的评价经颈静脉肝内门体分流术（TIPS）联合胃冠状静脉栓塞术（GCVE）治疗门静脉高压症上消化道出血的中远期疗效。方法回顾性分析昆明医科大学第二附属医院肝病中心2008年1月至2013年1月间99例因肝硬化门静脉高压症上消化道出血行TIPS手术治疗的患者。其中43例行单纯TIPS治疗（TIPS组）,56例行TIPS联合组织胶定位栓塞治疗（TIPS＋GCVE组）。测量、计算术前、术后两组患者直接门静脉压力（PVP）、门静脉压力梯度（PPG）。TIPS组、TIPS＋GCVE组术前与术后PVP、PPG比较应用t检验;随访期间TIPS组和TIPS＋GCVE组患者未发生上消化道再出血率、生存率和支架通畅率分析应用Kaplan-Meier法,进一步组间比较应用Log-rank检验。结果TIPS组、TIPS＋GCVE组术前PVP分别为（35.2±3.1）和（35.3±3.6）mm Hg（1 mm Hg=0.133 kPa）,术后PVP分别为（21.9±2.8）和（22.7±3.1）mm Hg;TIPS组、TIPS＋GCVE组术前PPG分别为（25.8±3.2）和（25.5±2.3）mm Hg,术后PPG分别为（11.6±1.7）和（12.8±1.5）mm Hg。两组患者术后PVP、PPG均较术前下降,且差异均有统计学意义（TIPS组：t=15.772、15.722,均P=0.000;TIPS＋GCVE组：t=31.069、31.096,均P=0.000）;而术前、术后两组PVP差异均无统计学意义。术前两组PPG差异无统计学意义,而术后TIPS＋GCVE组PPG高于TIPS组,且差异有统计学意义（t=-4.726,P=0.000）。术后随访1~54个月,平均（36.3±11.1）个月。TIPS组患者术后6、12、24、48个月累积未发生上消化道再出血率分别为90.7%、86.0%、76.7%和65.1%,而TIPS＋GCVE组患者分别为98.2%、92.6%、89.3%和85.7%,两组比较差异有统计学意义（χ^2=5.987,P=0.014）;TIPS组患者术后6、12、24和48个月累积支架通畅率分别为95.3%、88.4%、79.1%和72.1%,TIPS＋GCVE组患者分别为92.9%、87.5%、82.1%和78.6%,两组比较差异无统计学意义（χ^2=0.736,P=0.328）;TIPS组患者术后6、12、24和48月累积生存率分别为93.0%、88.4%、83.7%和72.1%;TIPS＋GCVE组患者分别为94.6%、92.9%、87.5%和80.4%,两组比较差异无统计学意义（χ^2=2.18,P=0.094）。结论 TIPS联合GCVE治疗门静脉高压症上消化道出血,疗效肯定,再出血率低,是一种安全、有效的治疗方法。

Objective To evaluate the mid-long-term clinical efficacy of transjugular intrahepatic portosystemic shunt（TIPS）combined with gastric coronary vein embolization（GCVE）for portal hypertension complicated with upper gastrointestinal bleeding.Methods Ninety-nine cirrhosis patients,who had received TIPS for upper gastrointestinal hemorrhage due to portal hypertension from January 2008 to January 2013 in the second affiliated hospital of Kunming Medical University,were retrospectively analyzed.Among these patients,43 received TIPS（TIPS group）and 56 received TIPS plus GCVE（TIPS＋GCVE group）.Portal venous pressure（PVP）and portal pressure gradient（PPG）of both groups before and after treatment were compared by t test.Upper gastrointestinal rebleeding rate,survival rate and stent patency rate in both groups during a follow-up were analyzed by Kaplan-Meier method,which was further compared by log-rank test between the two groups.Results Preoperative PVP in TIPS group and TIPS＋GCVE group were（35.2±3.1）,（35.3±3.6）mm Hg（1 mm Hg=0.133 kPa）,while postoperative PVP were（21.9±2.8）,（22.7±3.1）mm Hg;preoperative PPG in two groups were（25.8±3.2）,（25.5±2.3）mm Hg,while postoperative PPG were（11.6±1.7）,（12.8±1.5）mm Hg.Postoperative PVP and PPG were lower than preoperative ones in both groups,which showed statistically significant differences（TIPS group：t=15.772、15.722,P=0.000;TIPS＋GCVE group：t=31.069、31.096,P=0.000,respectively）.However,there was no significant difference in PVP before and after treatment between two groups.Between the two groups,preoperative PPG showed no significant difference,while postoperative PPG in TIPS＋GCVE group was statistically significantly higher than that in TIPS group（t=-4.726,P=0.000）.A1 l cases were followed up for1 to 54 months after operation with an average of（36.3±11.1）months.The free of variceal rebleeding rates in 6 months,12 months,24 months and 48 months after operation were 90.7%,86.0%,76.7% and 65.1% in TIPS group,respectively,and 98.2%,92.6%,89.3% and 85.7% in TIPS＋GCVE group,respectively,which revealed statistically significant differences（χ~2=5.987,P=0.014）.Stent patency rates in 6 months,12 months,24 months and 48 months after operation were 95.3%、88.4%、79.1% and 72.1% in TIPS group,respectively,and 92.9%、87.5%、82.1% and78.6%in TIPS＋GCVE group,respectively,which indicated no significant difference（χ~2=0.736,P=0.328）.Survival rates in 6 months,12 months,24 months and 48 months after operation were 93.0%、88.4%、83.7% and 72.1%in TIPS group,respectively,and 94.6%、92.9%、87.5% and 80.4%in TIPS＋GCVE group,respectively,which pointed out no significant difference（χ~2=2.18,P=0.094）.Conclusion The combined treatment of TIPS with GCVE could reduce rebleeding rate of esophageal and gastric varices,which is more effective than TIPS alone,with reliable security and satisfactory long-term efficacy.