经颈内静脉肝内门体分流术在门静脉海绵样变性患者中应用评价的Meta分析

Meta-analysis for assessing the application of transjugular intrahepatic portosystemic shunt in patients with cavernous transformation of the portal vein

背景与目的:目前临床上对于门静脉海绵样变性(CTPV)的治疗常用的方式包括内科药物治疗和外科手术治疗,而介入手术在该领域应用尚不广泛,该病一直以来被认为是经颈内静脉肝内门体分流术(TIPSS)禁忌证。随着近年来技术水平提升,以及相关操作器械的升级换代,TIPSS治疗逐渐在CTPV患者中开展。但目前TIPSS在CTPV患者群体中开展情况并不广泛,仅在部分有着丰富经验的血管介入中心实施,同时也缺乏循证学证据来证明其应用价值。本研究通过Meta分析评价TIPSS在CTPV患者中应用的可行性、有效性及安全性,以求获得循证学证据供临床参考。方法:检索多个国内外数据库收集相关文献,检索时间均为自建库至2020年2月,提取相关数据,将手术成功率、主要并发症的发生率、手术前后门体静脉压力梯度(PPG)、术后再出血率、术后肝性脑病发生率、12个月支架通畅率及12个月生存率指标作为结局指标。采用RevMan 5.1软件对数据进行Meta分析。发表偏倚的检测采用Stata 14软件进行定量分析。结果:根据纳入和排除标准,最终纳入了9篇研究,共188例接受TIPSS治疗的CTPV患者。合并的Meta分析结果显示,手术成功率为77%(95%CI=63%~87%,I^2=67%,P=0.0005)、手术主要并发症的发生率为22%(95%CI=11%~40%,I^2=59%,P=0.004)、手术后PPG明显降低(WMD=13.19,95%CI=11.86~14.52,I^2=58%,P<0.00001)、再出血率为12%(95%CI=7%~21%,I^2=0%,P<0.00001)、术后肝性脑病发生率为17%(95%CI=11%~25%,I^2=0%,P<0.00001)、12个月支架通畅率为81%(95%CI=73%~86%,I^2=0%,P<0.00001)、12个月生存率为89%(95%CI=81%~94%,I^2=16%,P<0.00001)。结论:TIPSS在CTPV患者中应用是可行、有效且安全的。但该项技术的成功实施离不开施术者丰富的经验及熟练的技艺,也必须结合术前的相关检查以及患者的情况充分评估权衡手术的风险利弊,严格把握适应证,制定合适的治疗方案,从而使得目标患者群体能够最大程度的获益。期待未来将TIPSS治疗变成合适的CTPV患者群体的一项常规治疗方式,且在未来达成较为统一的相关共识及操作标准。现阶段亟待更多的大样本、多中心的随机对照试验,进行充分比较各个因素,以指导临床在这一领域的决策。

Background and Aims:The common treatment methods for cavernous transformation of the portal vein(CTPV)include medical treatment and surgery,while interventional surgery is not usually used in this field,and this disease has long been considered to be a contraindication for transjugular intrahepatic portosystemic stent-shunt(TIPSS).With the improvement of technology and the upgrading of relevant operating devices in recent years,TIPSS is increasingly carried on in CTPV patients.However,the implementation of TIPSS for CTPV patients is not widespread at present,and it is only conducted in some vascular intervention centers with extensive experience.Meanwhile,there is also a lack of evidence-based data to prove its application value.This study was conducted to evaluate the feasibility,efficacy and safety of application of TIPSS in CTPV patient through a Meta-analysis,so as to obtain evidence-based information for clinical decision-making.Methods:The relevant literature was collected by searching a number of national and international database.The retrieval time was limited from the inception of each database to February 2020.After extraction of the relevant data,the success rate of surgery,the incidence of major complications,porto-systemic pressure gradient(PPG)before and after surgery,postoperative rebleeding rate,incidence of postoperative hepatic encephalopathy,12-month stent patency rate and 12-month survival rate were recorded as clinical outcome parameters.Meta-analysis of the data was performed by RevMan 5.1 software.Stata 14 software was used for quantitative analysis of publication bias detection.Results:Nine studies were included based on inclusion and exclusion criteria,involving a total of 188 CTPV patients who underwent TIPSS treatment.The pooled results of Meta-analysis showed that operation success rate was 77%(95%CI=63%–87%,I^2=67%,P=0.0005),the incidence of major surgical complications was 22%(95%CI=11%–40%,I^2=59%,P=0.004),the PPG was significantly reduced after operation(WMD=13.19,95%CI=11.86–14.52,I^2=58%,P<0.00001),the rebleeding rate was 12%(95%CI=7%–21%,I^2=0%,P<0.00001),the incidence of postoperative hepatic encephalopathy was 17%(95%CI=11%–25%,I^2=0%,P<0.00001),the 12-month patency rate of stent was 81%(95%CI=73%–86%,I^2=0%,P<0.00001),and the 12-month survival rate was 89%(95%CI=81%–94%,I^2=16%,P<0.00001).Conclusion:TIPSS is feasible,effective and safe in CTPV patients.However,the successful implementation of this technique cannot be achieved without relevant experience and specialized skills of the surgeon.It is also necessary to fully evaluate and weigh the risks and advantages of the operation based on the relevant preoperative examinations and the patient's condition,strict consideration of indications,and appropriate treatment plan making,so as to maximize the benefits of the target patient group.It is expected that TIPSS treatment will become a routine treatment for suitable CTPV patients,and a relatively unified consensus and operating standards will be reached in the future.At present stage,more large sample,multicenter randomized controlled trials are urgently needed to fully compare various factors to guide clinical decision-making in this field.