膨体聚四氟乙烯覆膜支架行经颈静脉肝内门体静脉分流术与药物联合胃镜治疗作为门静脉高压食管胃底曲张静脉破裂出血二级预防的疗效对比

Comparison of the curative effect of transjugular intrahepatic portosystemic shunt with expanded polytetrafluoroethylene-covered stent and drug combined with gastroscopy as the secondary prevention of esophageal-gastric variceal bleeding in portal hypertension

目的比较以膨体聚四氟乙烯(ePTFE)覆膜支架经颈静脉肝内门体静脉分流术(TIPS)与药物联合胃镜治疗作为门静脉高压食管胃底曲张静脉破裂出血二级预防的临床疗效。方法纳入2017年3月至7月因门静脉高压食管胃底曲张静脉破裂出血,在南方医科大学南方医院接受TIPS治疗(ePTFE覆膜支架)或首次接受胃镜治疗作为二级预防的患者,分析两组患者术后1年内肝功能变化、腹水缓解率、肝性脑病发生率、再出血率、平均住院次数及费用、生存时间,以及TIPS组支架通畅情况。对数据采用χ2检验、Kaplan-Meier法和Mann-Whitney U检验进行分析。结果TIPS组74例,药物联合胃镜组66例,随访12~16(14.57±0.79)个月。术后1年,TIPS组腹水缓解率为57.1%(32/56),高于药物联合胃镜组的0(χ2=36.73,P<0.01)。术后1、3、6、12个月,TIPS组患者肝性脑病的累积发生率分别为32.4%(24/74)、37.8%(28/74)、40.5%(30/74)、40.5%(30/74),药物联合胃镜组患者肝性脑病的累积发生率分别为3.0%(2/66)、3.0%(2/66)、3.0%(2/66)、6.1%(4/66);Kaplan-Meier分析显示,TIPS组肝性脑病累积发生率高于药物联合胃镜组(χ2=11.29,P<0.01)。术后1个月内、1~3个月、3~6个月、6~12个月,TIPS组重度肝性脑病(Ⅲ至Ⅳ度)的发生率分别为2.7%(2/74)、0、0、0,药物联合胃镜组重度肝性脑病发生率均为0,两组重度肝性脑病的发生率差异无统计学意义(P>0.05)。TIPS组和药物联合胃镜组术后12个月再发出血率分别为0和27.3%(18/66),差异有统计学意义(χ2=22.42,P<0.01)。随访期间两组均无患者死亡。TIPS组住院次数为(1.45±0.80)次,少于药物联合胃镜组的(3.24±1.80)次,差异有统计学意义(U=-4.52,P<0.01)。结论在预防食管胃底曲张静脉再出血方面,TIPS(ePTFE覆膜支架)治疗具有再出血率低、腹水缓解率高、住院次数少等优点;TIPS治疗患者肝性脑病发生率比药物联合胃镜的高,但TIPS并不增加重度肝性脑病发生率。TIPS与药物联合胃镜治疗的术后1年生存率无差异。

Objective To compare the clinical efficacy of transjugular intrahepatic portosystemic shunt(TIPS)with expanded polytetrafluoroethylene(ePTFE)-covered stent and drug combined with gastroscopy as the secondary prevention of esophageal-gastric variceal bleeding in portal hypertension.Methods Patients with esophageal-gastric variceal bleeding who received TIPS treatment(ePTFE covered stent)or gastroscopy for the first time as the secondary prevention for portal hypertension at Nanfang Hospital of Southern Medical University through March to July 2017 were selected.One year after the operation,liver function changes,ascites remission rates,incidence of hepatic encephalopathy,re-bleeding rate,average hospitalization frequency and expenses,survival time,as well as the TIPS patency conditions were analyzed in the two groups of patients.2 test,Kaplan-Meier method and Mann-Whitney U test were used to analyze the data.Results There were 74 and 66 cases in the TIPS and the drug combined gastroscopy group and the follow-up duration(14.57±0.79)was 12-16 months.One year after surgery,the remission rate of ascites in the TIPS group was higher 57.1%(32/56)than that of the drug combined gastroscopy group(0),and the difference was statistically significant(χ2=2=36.73,P<0.01).The cumulative incidence of hepatic encephalopathy at 1,3,6,and 12 months after surgery in the TIPS group was 32.4%(24/74),37.8%(28/74),40.5%(30/74),and 40.5%(30/74),respectively.The cumulative incidence of hepatic encephalopathy in the drug combined gastroscopy group was 3.0%(2/66),3.0%(2/66),3.0%(2/66),and 6.1%(4/66),respectively.Kaplan-Meier analysis showed that the cumulative incidence of hepatic encephalopathy in the TIPS group was higher than that of the drug combined gastroscopy group(χ2=11.29,P<0.01).The incidence of severe hepatic encephalopathy(grade III to IV)at 1,3,6,and 12 months after surgery in the TIPS group was 2.7%(2/74),0,0,and 0,respectively.The incidence of severe hepatic encephalopathy in drug combined gastroscopy group was 0,and there was no statistically significant difference in development of hepatic encephalopathy between the two groups(P>0.05).The re-bleeding rates of TIPS group and drug combined gastroscopy group were 0 and 27.3%(18/66),respectively,and the difference was statistically significant(χ2=22.42,P<0.01).There was no death reported during the follow-up period between both groups.The hospitalization frequency times(1.45±0.80)in TIPS group was lower than that of the drug combined gastroscopy group times(3.24±1.80),and the difference was statistically significant(U=-4.52,P<0.01).Conclusion In the prevention of esophageal-gastric variceal bleeding,TIPS(ePTFE-covered stent)treatment has the advantages of reducing re-bleeding rate,high ascites remission rate and hospitalizations frequency.In addition,patients treated with TIPS have a higher incidence of hepatic encephalopathy than that of drugs combined with gastroscopy.However,TIPS did not exacerbate the incidence of hepatic encephalopathy,and there was no significant difference in the 1-year survival rate after TIPS and drugs combined with gastroscopy treatment.