经颈静脉肝内门体分流术在56例肝硬化门脉高压并上消化道出血的疗效分析

A clinical study on transjugular intrahepatic portosystemic shunt for 56 patients with portal hypertension complicated by upper gastrointestinal bleeding

目的分析经颈静脉肝内门体分流术(transjugular intrahepatic portosystemic shunt,TIPS)在治疗肝硬化门脉高压并上消化道出血的疗效及并发症。方法采用回顾性分析方法,对2014年3月至2017年11月应用TIPS治疗的56例肝硬化门脉高压并上消化道出血的患者进行随访,随访截止2017年11月30日。采用SPSS20.0软件包对术前、术后门脉压力、肝功能、血肌酐数据进行分析,并随访术后支架通畅情况。结果所有患者均成功建立肝内门腔支架分流道,技术成功率100%。2例患者行覆膜支架植入,3例患者行裸支架植入,28例患者行裸支架+覆膜支架植入,23例患者行Viatorr支架植入,支架直径7～10 mm[(8.7±0.4)mm]。门脉压力(portal vein pressure,PVP)由术前(30.9±7.0) mmHg降至术后(17.2±3.6)mmH g,差异有统计学意义(t=17.421,P<0.05)。1例患者术后出现梗阻性黄疸(胆道结石引起),行经皮经肝胆道引流术(percutaneous transhepatic cholangio drainage,PTCD)后,黄疸好转,2例患者出现围术期并发症死亡,余53例术前总胆红素(total bilirubin,TBIL)、总蛋白(total protein,TP)、谷草转氨酶(aspartate aminotransferase,AST)、谷丙转氨酶(alanine aminotransferase,ALT)、血肌酐(serum creatinine,SCr)与术后1周、3个月进行比较。术后1周的TBIL、AST、ALT水平较术前升高[TBIL:(30.7±16.7)μmol/L v.s.(23.6±12.2)μmol/L;AST:(103.8±163.6) U/L v.s(. 39.2±24.5) U/L;ALT:(86.9±144.3) U/L v.s.(33.5±17.3)U/L],差异均有统计学意义(P<0.05),TP、SCr水平差异无统计学意义;术后3月的TBIL、AST、ALT水平较术前差异无统计学意义,TP水平较术前升高[(37.7±10.5)g/L v.s(. 31.5±7.3)g/L],SCr水平较术前下降[(71.5±46.1)μmol/L v.s.(75.1±53.1)μmol/L],差异均有统计学意义(P <0.05)。除2例围术期死亡,余54例随访时间17天至44个月,支架狭窄或闭塞5例(再发上消化道出血1例),其中3例再次介入治疗,发生肝性脑病(hepatic encephalopathy,HE)4例,进展为原发性肝癌2例。结论 TIPS能显著降低门脉压力,在治疗肝硬化门脉高压并上消化道出血疗效肯定,短期内对肝功能有一定影响,但从中期来看,对肝功能影响小,对肾功能有改善作用,是一种安全、有效的方法。

Objective To analyse the clinical effect and complications for transjugular intrahepatic portosystemic shunt（TIPS） in treating portal hypertension complicated by upper gastrointestinal bleeding. Methods A retrospective analysis was performed on the 56 patients with portal hypertension complicated by upper gastrointestinal bleeding who underwent TIPS from March 2014 to November 2017. Preoperative and postoperative level of portal veinpressure, liver function, serum creatinine were analyzed using SPSS 20.0, and the patency of stents was followed up. Results The procedures were successful in all 56 patients.Two patients had been implanted with the coated stent. Three patients had been implanted with the bare sent. Twenty-eight patients had been implanted with the bare sent and coated stent. Twenty-three patients had been implanted with Viatorr. The diameter of stent was 7 ～ 10 mm[（8.7±0.4） mm]. The portal vein pressure（PVP） declined from （30.9±7.0） mmHg to （17.2±3.6） mmHg after operation. The difference was statistically significant （t=17.421, P〈 0.01）. Except for 1 patient who suffered from obstructive jaundice after operation caused by biliary calculi and was improved by percutaneous transhepatic cholangio drainage, as well as 2 patients who died of perioperative complication, the rest of the cases without complications were selected. The preoperative total bilirubin （TBIL）, total protein（TP）, aspartate aminotransferase（AST）, alanine aminotransferase（ALT） and serum creatinine （SCr） were compared with those 1 week and 3 months after operation. TBIL, AST and ALT increased 1 week after operation and the difference was statistically significant （P〈0.05） while there was no significant difference in TP and SCr. There were no significantly difference in TBIL, AST and ALT 3 months after operation. However, TP was significantly higher and SCr was lower than those before operation. Except for 2 cases of perioperative death, the rest of the cases were followed up for 17 days to 44 months, including 5 cases of stent stenosis or occlusion （1 case of recurrent hemorrhage of upper gastrointestinal tract）, 3 cases of retreatment, 4 cases of hepatic encephalopathy（HE） and 2 cases of primary liver cancer. Conclusion TIPS can effectively relieve the portal venous hypertension, and it is a safe and effective method in treating the portal hypertension complicated by upper gastrointestinal bleeding. In the short term, it has a certain effect on the liver function, but in the medium term, it has little influence on the liver function and improves the renal function.