TIPS治疗脾切除联合断流术后复发性门静脉高压伴上消化道出血的疗效分析

Efficacy of TIPS in treatment of recurrent portal hypertension after splenectomy and devascularization in patients presenting with upper gastrointestinal bleeding

目的探讨脾切除联合断流术后复发性门静脉高压伴上消化道出血的肝硬化患者经颈静脉肝内门体分流术(TIPS)治疗的疗效、可行性及安全性。方法选取徐州医科大学附属医院2015年8月至2020年12月脾切除联合断流术后复发门静脉高压伴上消化道出血的肝硬化患者。共纳入39例患者,男性24例,女性15例,年龄(51.56±9.08)岁。采用Viabahn支架对患者行TIPS治疗,记录术中门静脉压力、手术成功率、止血率,术后复查血液学指标,观察术后疗效及并发症发生率。结果39例患者中38例成功建立TIPS分流道,1例因门静脉海绵样变性失败,成功率97.44%(38/39),无手术相关致死性并发症。38例患者共植入8 mm直径Viabahn支架39枚,其中33例(86.84%)将支架次全扩张至6 mm直径,剩余5例将支架完全扩张至8 mm标称直径。术后止血率97.37%(37/38)。TIPS术前的门静脉压力、门静脉压力梯度分别由(31.28±6.24)、(20.61±5.14)mmHg(1 mmHg=0.133 kPa)降至术后的(19.58±4.69)、(9.24±3.07)mmHg,差异有统计学意义(均P<0.001)。随访3~36个月,中位随访时间12个月。术后再出血率6.90%(2/29)、肝性脑病发生率13.79%(4/29)、分流道失功率13.79%(4/29)。结论TIPS是脾切除联合断流术后复发性门静脉高压伴上消化道出血患者的安全、有效、可行的治疗方法,多数患者使用6 mm直径的分流道即可获得较好的临床疗效。

Objective To study the efficacy,feasibility and safety of transjugular intrahepatic portosystemic shunt(TIPS)in treatment of recurrent portal hypertension after splenectomy and devascularization in patients presenting with upper gastrointestinal bleeding.Methods Cirrhotic patients with recurrent portal hypertension after splenectomy and devascularization and presenting with upper gastrointestinal bleeding from August 2015 to December 2020 were studied.Thirty-nine patients were included in this study.There were 24 males and 15 females,with age of(51.56±9.08)years old.These patients were treated with TIPS by using the Viabahn stent.Intraoperative portal vein pressure,success operative rate,hemostasis rate after surgery,changes in hematological indicators and postoperative efficacy and complication rate were studied.Results Thirty-eight of 39 patients successfully underwent TIPS shunt and 1 patient failed because of portal vein spongiosis.The success rate was 97.44%(38/39).Thirty-three patients underwent TIPS and variceal vein embolization,while 5 patients were treated with TIPS alone.Thirty-nine Viabahn stents with a diameter of 8 mm were implanted in 38 patients,of which 5 patients had the stent expanded to its nominal diameter of 8 mm.The remaining 33 patients(86.84%)had a shunt with a diameter of 6 mm.The hemostasis rate of postoperative gastrointestinal bleeding was 97.37%(37/38).The portal vein pressure and portal venous pressure gradient decreased from(31.28±6.24),(20.61±5.14)mmHg(1 mmHg=0.133 kPa)to(19.58±4.69),(9.24±3.07)mmHg respectively,the differences were significant(all P<0.001).All patients were followed-up for 3 to 36 months,with a median follow-up of 12 months.The postoperative rebleeding rate was 6.90%(2/29).The incidence of hepatic encephalopathy was 13.79%(4/29),and the incidence of shunt disorder was 13.79%(4/29).Conclusion TIPS was safe,effective and feasible in treating patients with recurrent portal hypertension after splenectomy and devascularization presenting with upper gastrointestinal bleeding.Most patients obtained good clinical outcomes with a 6 mm diameter shunt.