经颈静脉肝内门体分流术后肝性脊髓病的临床特征分析

Hepatic myelopathy after transjugular intrahepatic portosystemic shunt:natural course,survival analysis,and treatment

目的研究经颈静脉肝内门体分流术（TIPS）后肝性脊髓病（HM）的特征。方法回顾性纳入第四军医大学西京消化病医院消化介入科2005年-2014年肝硬化门静脉高压经TIPS手术成功治疗后发生HM的连续病例。所有患者于TIPS术后1、3、6个月以及之后每半年进行常规随访。根据疾病进展时间总结HM的自然病程,计量资料组间比较采用独立样本t检验;计数资料组间比较采用χ2检验。通过Kaplan-Meier法进行生存分析,并用Cox比例风险回归模型筛选其预后的预测因素,统计患者下肢症状缓解情况以分析其治疗效果。结果从HM 1级发展到2、3、4级的时间分别为4.0（1～36）个月、8.5（1～44个月和18.87（5.4～48.6）个月。HM患者1、3和5年累计生存率分别为84.19%、51.86%和45.21%。HM发病年龄[风险比（HR）=1.034,95%可信区间（95%CI）：1.003～1.065]和再发腹水（HR=3.869,95%CI：1.623～9.225）是HM患者预后的独立预测因素。肝移植后症状缓解者所占比例显著高于未经肝移植者（χ2=13.5,P=0.003）,而支架限流或封堵的效果差异无统计学意义（P〉0.05）。结论HM的病程通常由快速进展期和平台期构成,TIPS术后HM患者生存情况较好,而目前肝移植是治疗HM有效的方法。

Objective To investigate the features of hepatic myelopathy （HM） after transjugular intrahepatic portosystemic shunt （TIPS）. Methods A retrospective analysis was performed for a consecutive cohort of patients with cirrhotic portal hypertension who were successfully treated with TIPS in Department of Liver Disease and Digestive Interventional Radiology in Xijing Hospital of Digestive Diseases, Fourth Mil- itary Medical University, from 2005 to 2014 and then developed HM. Routine follow - up was performed for all patients at 1, 3, and 6 months after TIPS and every half a year subsequently. The time to disease progression was used to summarize the natural course of HM, the comparison of continuous data was made by independent samples t - test, the comparison of categorical date was made by chi - square test. The Kaplan - Meier method was used for survival analysis, and the Cox proportional hazards regression model was used to determine prognos- tic factors. Relief of symptoms in the lower limbs was analyzed to investigate the therapeutic effect. Results The time to HM progression from gradel to grades 2, 3, and 4 was 4.0 months （range, 1 -36 months）, 8.5 months （range, 1 -44 months）, and 18.8 months （ range, 5.4 - 48.6 months） , respectively. In HM patients, the 1 - , 3 - , and 5 - year cumulative survival rates were 84.19% , 51.86% , and 45.21% , respectively. Age of HM onset （ HR = 1. 034, 95% CI： 1. 003 - 1. 065 ） and recurrent ascites （ HR = 3. 869, 95% CI ： 1. 623 - 9. 225 ） were independent prognostic factors in patients with HM. The patients who underent liver transplantation had a significant- ly higher proportion of patients with relief of symptoms than those who did not undergo liver transplantation （X2 = 13.5, P = 0. 003 ） , while the effects of stent flow limitation and occlusion showed no significant differences （ P 〉 0.05 ）. Conclusion The course of HM consists of rapid progression stage and plateau stage, and HM patients after TIPS show good survival. At present, liver transplantation is an effective method to treat HM.