TIPS联合TACE治疗肝癌伴门静脉高压食管胃静脉曲张出血的临床疗效

Efficacy of Transjugular Intrahepatic Portosystemic Shunt Combined with Transcatheter Arterial Chemoembolization for Hepatocellular Carcinoma Complicated with Portal Hypertension Related Esophageal and Gastric Variceal Bleeding

目的评价肝癌伴门静脉高压食管胃静脉曲张破裂出血(EGVB)患者行经颈静脉肝内门体分流术(TIPS)联合经动脉化疗栓塞术(TACE)的安全性及疗效。方法16例肝癌伴门静脉高压EGVB的患者施行TIPS联合TACE治疗,男11例,女5例,年龄49~74岁,平均(59.5±8.4)岁。术后1、3、6、12个月及以后每3个月采用彩色多普勒超声和上腹部增强CT进行随访。TACE术后1个月采用改良实体肿瘤疗效评价标准(mRECIST)评价肝癌疗效。采用Kaplan-Meier曲线评估存活率。结果16例患者TIPS技术成功率100%,门静脉压力梯度(PPG)由术前平均(36.5±4.9)mmHg降至术后平均(8.2±2.5)mmHg(t=18.595,P<0.01)。16例患者共施行36次TACE,术后出现肝脓肿1例,经穿刺引流脓腔消失。16例患者随访3~122个月,平均(34.9±34.3)个月。TIPS联合TACE治疗术后1个月完全缓解(CR)、部分缓解(PR)、疾病稳定(SD)、疾病进展(PD)分别为6、5、2、3例。TIPS术后24个月支架内再狭窄1例,经再次球囊扩张后通畅。随访期间全部患者均无再次出血;出现轻度肝性脑病3例、肝性脊髓病1例;死亡3例。术后3、6、12、24、36个月累积生存率分别为100%、91.7%、83.3%、83.3%、83.3%。结论TIPS联合TACE治疗肝癌伴门静脉高压EGVB是安全、有效的方法。

Objective To evaluate the safety and efficacy of transjugular intrahepatic portosystemic shunt(TIPS)combined with transarterial chemoembolization(TACE)in the treatment of hepatocellular carcinoma with portal hypertension related esophageal variceal bleeding(EGVB).Methods Sixteen hepatocellular carcinoma patients complicated with portal hypertension related EGVB underwent TIPS combined with TACE.There were 11 males and 5 females,aged 49-74,mean(59.5±8.4)years old.Color Doppler ultrasound and enhanced CT were performed at 1,3,6,12 months after treatment and then every 3 months.mRECIST was used to evaluate the efficacy of hepatocellular carcinoma 1 month after TACE.Cumulative survival rates were generated by the Kaplan-Meier method.Results The success rate of TIPS was 100%in 16 patients.The portal venous pressure gradient dropped from the mean(36.5±4.9)mmHg before treatment to the mean(8.2±2.5)mmHg after treatment(t=18.595,P<0.05).A total of 36 times of TACE were performed in 16 patients.Live abscess occurred in one patient and was absorbed after percutaneous transhepatic drainage.The 16 patients were followed up for 3-122 months,mean(34.9±34.3)months.CR,PR,SD and PD was achieved in 6,5,2 and 3 cases one month after the combination treatment,respectively.One case experienced stent restenosis 24 months after TIPS,and the shunt patency was again achieved after another balloon dilation.During the follow-up,there was no rebleeding.Mild hepatic encephalopathy and hepatic myelopathy occurred in 3 and 1 case,respectively.Three patients died.The overall cumulative 3,6,12,24 and 36 month survival rates were 100%,91.7%,83.3%,83.3%and 83.3%,respectively.Conclusion TIPS combined with TACE is a safe and effective method in the treatment of hepatocellular carcinoma complicated with portal hypertension related EGVB.