经皮经肝肝内门体分流术的手术方法与临床应用

Technical protocol and clinical application of percutaneous transhepatic intrahepatic portosystemic shunt

目的介绍经皮经肝肝内门体分流术(PTIPS)的手术方法及围术期情况。方法 2009年11月—2013年3月,76例门静脉高压患者接受经门静脉右支PTIPS,临床表现为消化道出血69例(其中23例合并不同程度腹腔积液),单纯性顽固性腹腔积液7例。术前肝功能Child-Pugh A级23例,B级35例,C级18例。上腹部CT/MRI显示34例肝脏重度萎缩,肝裂明显增宽;25例伴门静脉血栓/癌栓形成合并门静脉海绵样变性。经皮成功穿刺门静脉右下分支后,沿同一穿刺道经门静脉"逆行"穿刺肝静脉或肝段下腔静脉,建立肝内门体分流道。结果 76例患者PTIPS成功率100%。门静脉压差由术前(32.35±2.89)mm Hg降至术后(18.42±1.32)mm Hg(P<0.001)。2例患者发生腹腔出血,栓塞相应肝动脉后治愈。1例肝功能C级患者术后5天因肝衰竭死亡,余75例患者术后1个月内门脉高压症状消失。结论 PTIPS是传统经颈静脉肝内门体分流术(TIPS)的补充,是一种安全、有效的治疗方法,手术成功率高,大大拓展了介入性门体分流术的应用范围。

Objective To introduce the technical protocol and clinical application of percutaneous transhepatic intrahepatic portosystemic shunt（PTIPS）.Methods Between November 2009 and March 2013,76 patients with symptomatic portal hypertension underwent PTIPS due to bleeding varices（n=69）,refractory ascites（n=7）,and bleeding varices combining with refractory ascites（n=23）.The severity of liver disease was Child-Pugh A in 23 cases,Child-Pugh B in 35,and Child-Pugh C in 18.The CT or MR image manifested serious hepatatrophy in 34 cases and cavernous transformation of portal vein（CTPV） in 25 cases.Under fluoroscopic guidance,the portal vein（PV） was punctured.Then,the hepatic vein（HV） or retrohepatic inferior vena cava（RIVC） was punctured PTIPS procedure was completed in the standard transjugular fashion.Results The procedure was technically successful in all patients.And effective portal decompression and free antegrade shunt flow were achieved.The mean portal pressure gradient decreased from（32.35±2.89） mm Hg to（18.42±1.32） mm Hg before and after PTIPS creation respectively,and the difference was significant statistically（P〈0.001）.Of the 76 patients,abdominal hemorrhage occurred in 2 cases,which was cured by artery embolization.One patient developed hepatic coma and died after 5 days while the other 75 patients survived and the symptoms of portal hypertension disappeared in one month.Conclusions PTIPS is both safe and effective in treatment of portal hypertension with exceptionally challenging anatomy.It is an available supplement for transjugular intrahepatic portosystemic shunt.It can extend the application scope of interventional portosystemic shunt.