经颈静脉肝内门体分流术在门静脉高压并发顽固性腹水及静脉曲张出血患者个体化治疗中的初步应用

Preliminary application of transjugular intrahepatic portosystemic shunt in individualized treatment of patients with cirrhotic portal hypertension complicated with refractory ascites and variceal hemorrhage

目的探讨经颈静脉肝内门体分流术(TIPS)在门静脉高压并发顽固性腹水及静脉曲张出血患者个体化治疗的可行性、疗效及安全性。方法前瞻性研究2017年8月至2018年12月徐州医科大学附属医院收治的因门静脉高压行TIPS个体化治疗的47例患者临床资料,男26例、女21例,年龄23~75(52±14)岁。采用Viabahn支架控制分流道直径并依据术前肝功能Child-Pugh分级制定个体化的TIPS术后PPG的预设区间值,其中Child A、B级患者术后PPG<10 mm Hg(1 mmHg=0.133 kPa),Child C级患者术后PPG区间值为12~15 mmHg。记录手术成功率、止血率、腹水缓解率、并发症发生率情况。结果47例患者手术成功率100%,无手术相关致死性并发症。Child-Pugh A、B级的患者与Child-Pugh C级的患者门静脉压力梯度分别由术前(22.5±5.4)(24.4±2.6)mmHg,降为术后(8.8±2.5)、(13.2±1.1)mmHg(均P<0.05)。随访6~24个月,中位随访时间13个月。上消化道出血患者止血成功率93.5%(29/31)、顽固性腹水缓解率14/16例、术后再出血率6.5%(2/31)、肝性脑病发生率8.5%(4/47)、分流道失功率2.1%(1/47)。结论使用Viabahn支架行个体化TIPS治疗门脉高压并发顽固性腹水及静脉曲张出血技术方法可行,临床疗效肯定,可降低术后肝性脑病发生率及分流道失功率。

Objective To investigate the feasibility,efficacy and safety of transjugular intrahepatic portosystemic shunt(TIPS)in the individualized treatment of patients with refractory ascites and variceal hemorrhage caused by portal hypertension.Methods Prospective study of clinical data of 47 patients with portal hypertension and refractory ascites and variceal bleeding admitted to the Affiliated Hospital of Xuzhou Medical University from August 2017 to December 2018,26 males and 21 females,aged 23-75(52±14)years old.The Viabahn stent was used to control the diameter of the shunt and the preoperative interval of PPG after individualized TIPS was determined according to the preoperative liver function Child-Pugh classification.The PPG of the Child A and B patients was<10 mm Hg(1 mmHg=0.133 kPa),Child-Pugh C grade patients with postoperative PPG interval values of 12 to 15 mmHg.The success rate,hemostasis rate,ascites remission rate,and complication rate were recorded.Results Forty-seven patients were with a success rate of 100%,and there was no surgically related fatal complications.The portal pressure gradients of patients with Child-Pugh A,B and Child-Pugh C were reduced from preoperative(22.5±5.4),(24.4±2.6)mm Hg to postoperative(8.8±2.5),(13.2±1.1)mm Hg(all P<0.05).All the patients were followed up for 6 to 24 months,with a median follow-up of 13 months.The success rate of hemostasis in patients with upper gastrointestinal bleeding was 93.5%(29/31),the remission rate of patients with refractory ascites was 14/16,the postoperative rebleeding rate was 6.5%(2/31),the incidence of hepatic encephalopathy was 8.5%(4/47),and the shunt disorder was 2.1%(1/47).Conclusion The use of Viabahn stent for individualized TIPS in the treatment of portal hypertension with refractory ascites and variceal hemorrhage is feasible,and the clinical efficacy is affirmative,which can reduce the incidence of postoperative hepatic encephalopathy and shunt dysfunction.