内镜与经颈静脉肝内门体分流术治疗静脉曲张出血合并门静脉血栓的对比研究

Comparison of endoscopic and intrahepatic portosystemic shunt for variceal bleeding combined with portal vein thrombosis

目的比较经颈静脉肝内门体分流术(transjugular intrahepatic portosystemic shunt,TIPS)和内镜手术治疗肝硬化合并食管胃静脉曲张出血(esophageal gastric variceal bleeding,EGVB)伴门静脉血栓(portal vein thrombosis,PVT)的有效性和安全性。方法回顾性分析南京大学医学院附属鼓楼医院与温州医科大学附属第一医院2017年1月至2019年12月经TIPS或内镜治疗的183例肝硬化EGVB伴PVT患者资料,其中内镜治疗66例,TIPS治疗117例。按照1∶1进行倾向性评分匹配,最终筛选出接受内镜治疗与TIPS治疗的患者各58例。两组患者中位随访时间均为36个月。使用Kaplan‑Meier生存曲线分析两组患者术后生存率、术后再出血率、术后肝性脑病发生率等指标。结果在随访期间,内镜组患者的术后再出血率显著高于TIPS组[39.7%(23/58)比17.2%(10/58),P=0.005],TIPS组术后有更高的肝性脑病发生率[29.3%(17/58)比13.8%(8/58),P=0.048],内镜组与TIPS组患者的生存率差异无统计学意义[74.1%(43/58)比75.9%(44/58),P=0.769]。在PVT程度为轻度的亚组分析中,内镜组与TIPS组患者的生存率[88.0%(22/25)比72.0%(18/25),P=0.164]、再出血率[28.0%(7/25)比12.0%(3/25),P=0.164]、肝性脑病发生率[8.0%(2/25)比20.0%(5/25),P=0.202]差异均无统计学意义。在PVT程度为重度的亚组分析中,内镜治疗后再出血率高于TIPS组[48.5%(16/33)比21.2%(7/33),P=0.010],肝性脑病发生率低于TIPS组,但差异无统计学意义[18.2%(6/33)比36.4%(12/33),P=0.133],生存率差异亦无统计学意义[63.6%(21/33)比78.8%(26/33),P=0.154]。结论对合并有轻度PVT和EGVB的肝硬化患者,内镜下标准治疗联合抗凝可能优于TIPS;但对重度PVT患者,TIPS因显著降低再出血率,且未明显增加肝性脑病发生率,可能是更合适的选择。

Objective To compare the efficacy and safety of transjugular intrahepatic portosystemic shunt(TIPS)and endoscopic treatment for liver cirrhosis with esophageal gastric variceal bleeding(EGVB)and portal vein thrombosis(PVT).Methods A total of 183 liver cirrhosis patients with EGVB and PVT in Nanjing Drum Tower Hospital,the Affiliated Hospital of Nanjing University Medical School and the First Affiliated Hospital of Wenzhou Medical University were selected from January 2017 to December 2019,and 66 patients were assigned to the endoscopic group(received endoscopi treatment)and 117 the TIPS group(received TIPS treatment).Propensity score matching was performed according to the 1∶1 ratio,yielding 58 patients in each group for analysis,with a median follow-up time of 36 months in both groups.Postoperative survival,postoperative rebleeding rate,and postoperative hepatic encephalopathy incidence were assessed using Kaplan-Meier survival curves.Results During the follow-up,the rebleeding rate in the endoscopic group was significantly higher[39.7%(23/58)VS 17.2%(10/58),P=0.005],and the TIPS group had a higher incidence of postoperative hepatic encephalopathy[29.3%(17/58)VS 13.8%(8/58),P=0.048],and no significant difference in survival rate was observed between the two groups[74.1%(43/58)VS 75.9%(44/58),P=0.769].In the subgroup analysis of mild degree of PVT,there was no significant difference in survival[88.0%(22/25)VS 72.0%(18/25),P=0.164],rebleeding rate[28.0%(7/25)VS 12.0%(3/25),P=0.164],or incidence of hepatic encephalopathy[8.0%(2/25)VS 20.0%(5/25),P=0.202]between the endoscopic group and the TIPS group.In the subgroup analysis of severe degree of PVT,the rebleeding rate in the endoscopic group was significantly higher than that in the TIPS group[48.5%(16/33)VS 21.2%(7/33),P=0.010],while there was no significant difference in the incidence of hepatic encephalopathy[18.2%(6/33)VS 36.4%(12/33),P=0.133],or the survival rate[63.6%(21/33)VS 78.8%(26/33),P=0.154].Conclusion For liver cirrhosis patients with mild PVT and EGVB,combining endoscopic therapy with anticoagulation may be superior to TIPS.Conversely,in patients with severe PVT,TIPS may be a more suitable option due to a significantly reduced rebleeding risk without a notable increase in hepatic encephalopathy incidence.