We report two cases of hepatic encephalopathy caused by molecular targeted drugs after the Transjugular intrahepatic portosystemic shunt(TIPS)procedure in our center.The liver toxicities and anti-angiogenic effects in...We report two cases of hepatic encephalopathy caused by molecular targeted drugs after the Transjugular intrahepatic portosystemic shunt(TIPS)procedure in our center.The liver toxicities and anti-angiogenic effects induced by targeted drugs may generate an imbalance in ammonia metabolism,elevating blood ammonia levels.TIPS diverts partial blood supply from the liver,aggravates liver impairment,and shunts ammonia-rich blood from the intestine into the systemic circulation.These may be the mechanisms leading to hepatic encephalopathy caused by molecular targeted drugs following TIPS.When clinicians choose molecular targeted therapy as the second or third targeted therapy for patients who have undergone TIPS,the consequence of drug-induced hepatic encephalopathy should also be considered.展开更多
Background and aims:The present treatment goal of the transjugular intrahepatic portosystemic shunt(TIPS)is a portosystemic pressure gradient of12 mmHg or its reduction by>50%.This study relates the stent diameter...Background and aims:The present treatment goal of the transjugular intrahepatic portosystemic shunt(TIPS)is a portosystemic pressure gradient of12 mmHg or its reduction by>50%.This study relates the stent diameter to the reduction of the pressure gradient and attempts to predict the appropriate stent diameter necessary to reach the treatment goal.Methods:Pressure response,super response,and poor response were investigated in 208 de-novo TIPS patients and defined as post-TIPS gradients between>6 and 12 mmHg,6 mmHg,or not reaching the goal(>12 mmHg,reduction<50%),respectively.Pressures were related to the smallest stent diameters measured by planimetry of the radiographic image.Results:Responders(65%),super responders(26%),or poor responders(9%)had comparable stent diameters of 7.21.0 mm,but different post-TIPS gradients(9.71.9 mmHg,4.51.5 mmHg,and 14.21.4 mmHg,p<0.001),relative reduction of pre-TIPS gradients(51.711.4%,73.611.1%,and 34.09.1%,p<0.001),and specific reduction per mm of stent diameter(7.52.0%/mm,10.12.0%/mm,and 4.81.4%/mm,p<0.001).Prediction of the stent diameter required to reach response was not possible.Only two super responders had a stent diameter of<6 mm.Super and poor responders differed by the increase in the right atrial pressure(+5.0 mmHg vs.+3.1 mmHg,p=0.026)and reduction in the portal vein pressure(-8.6 mmHg vs.-4.6 mmHg,p<0.001).Conclusion:Most patients reached the treatment goal with stent diameters of<8 mm.Overtreatment(super response,gradient ≤6 mmHg)can be prevented by stent diameters as small as 6 mm.The individual response was not related to the stent diameter and not predictable.Cardiac dysfunction may play an important role by its effect on the right atrial(preload)and portal pressure(afterload).展开更多
Transjugular intrahepatic portosystemic stent‐shunt(TIPS)was first reported in 1989 as a nonsurgical percutaneous method for treating patients suffering from severe end‐stage portal hypertension symptoms with Child&...Transjugular intrahepatic portosystemic stent‐shunt(TIPS)was first reported in 1989 as a nonsurgical percutaneous method for treating patients suffering from severe end‐stage portal hypertension symptoms with Child's stage C metabolic status at Freiburg University Hospital in Germany.1 Since then,TIPS has become a unique percutaneous technique for treating portal hypertension,and it has spread throughout the world.In the early 1990s,medical standards in China lagged far behind Western countries,and interventional radiology(IR)depended heavily on imported medical instruments.During that period,IR doctors and scientists who received training abroad came back to China and began to use stenting techniques at a time when imported stent products were extremely scarce.Dr.Ke Xu,who received IR training in Japan in the late 1980s,treated a male patient with cirrhosis combined with repeated hematemesis with TIPS in the First Hospital of China Medical University in June 1992,which was certified the first case of TIPS in China(Figure 1A).展开更多
Background and Aim:Gastric varices are associated with high mortality.There have been conflicting reports on whether endoscopic treatment with cyanoacrylate or the placement of a transjugular intrahepatic portosystemi...Background and Aim:Gastric varices are associated with high mortality.There have been conflicting reports on whether endoscopic treatment with cyanoacrylate or the placement of a transjugular intrahepatic portosystemic shunt(TIPS)is more effective in the treatment of gastric varices.We compared the outcomes of patients treated with cyanoacrylate glue or TIPS for the management of acute gastric variceal bleeding.Methods:The study was designed as a retrospective cohort analysis of patients undergoing either TIPS or endoscopic treatment with cyanoacrylate for acute gastric variceal bleeding at our institution from 2001 to 2011.Primary compared to studied between the two treatment modalities were the short-term treatment outcomes,including re-bleeding within 30 days,length of hospital stay and in-hospital mortality.Kaplan-Meier survival analysis was performed to assess factors associated with in-hospital mortality.Results:A total of 169 patients were included in the analysis.The TIPS arm contained 140 patients and the cyanoacrylate arm contained 29 patients.There was no evidence to suggest any significant differences in demographics or disease severity.There were no differences between the TIPS arm and the cyanoacrylate armtwo groups in treatment outcomes including re-bleeding within 30 days(17.4%vs.17.2%;P=0.98),median length of stay in the hospital(4.5 days vs.6.0 days;P紏0.35)or in-hospital mortality(9.0%vs.11.1%;P=0.74).In-hospital mortality was evaluated for 149 patients and lower albumin(P=0.015),higher MELD score(P<0.001),higher CTP score(P=0.005)and bleeding(P=0.008)were all significantly associated with in-hospital death.Conclusion:These findings suggest that both treatments are equally effective.Cyanoacrylate offers a safe,effective alternative to TIPS for gastric varices,and physician may choose the best therapy for each patient,factoring in the availability of TIPS or cyanoacrylate,the individual patient’s presentation,and cost.展开更多
Patient prognosis after transjugular intrahepatic portosystemic shunt(TIPS)placement is relatively poor and highly heterogeneous;therefore,a prognostic scoring system is essential for survival prediction and risk stra...Patient prognosis after transjugular intrahepatic portosystemic shunt(TIPS)placement is relatively poor and highly heterogeneous;therefore,a prognostic scoring system is essential for survival prediction and risk stratification.Conventional scores include the Child–Turcotte–Pugh(CTP)and model for end‐stage liver disease(MELD)scores.The CTP score was created empirically and displayed a high correlation with post‐TIPS survival.However,the inclusion of subjective parameters and the use of discrete cut‐offs limit its utility.The advantages of the MELD score include its statistical validation and objective and readily available predictors that contribute to its broad application in clinical practice to predict post‐TIPS outcomes.In addition,multiple modifications of the MELD score,by incorporating additional predictors(e.g.,MELD‐Sodium and MELD‐Sarcopenia scores),adjusting coefficients(recalibrated MELD score),or combined(MELD 3.0),have been proposed to improve the prognostic ability of the standard MELD score.Despite several updates to conventional scores,a prognostic score has been proposed(based on contemporary data)specifically for outcome prediction after TIPS placement.However,this novel score(the Freiburg index of post‐TIPS survival,FIPS)exhibited inconsistent discrimination in external validation studies,and its superiority over conventional scores remains undetermined.Additionally,several tools display potential for application in specific TIPS indications(e.g.,bilirubin‐platelet grade for refractory ascites),and biomarkers of systemic inflammation,nutritional status,liver disease progression,and cardiac decompensation may provide additional value,but require further validation.Future studies should consider the effect of TIPS placement when exploring predictors,as TIPS is a pathophysiological approach that substantially alters systemic hemodynamics and ameliorates bacterial translocation and malnutrition.展开更多
Objective:Primary sclerosing cholangitis(PSC)occurs in approximately 5%of patients with ulcerative colitis(UC).The risk of colon cancer is higher in patients undergoing colectomy,who have simultaneous PSC&UC.Our a...Objective:Primary sclerosing cholangitis(PSC)occurs in approximately 5%of patients with ulcerative colitis(UC).The risk of colon cancer is higher in patients undergoing colectomy,who have simultaneous PSC&UC.Our aim was to study the impact,in terms of post-colectomy survival and complications,of transjugular intrahepatic portosystemic shunt(TIPS)before colectomy in these patients.Methods:In this retrospective,case-control study,information was obtained on demographics,disease characteristics,TIPS characteristics,and post-colectomy complications.Nine patients with PSC and UC who underwent TIPS prior to colectomy(the Study group)and 37 patients with PSC and UC who underwent only colectomy without TIPS(the Control group)were included.Either an analysis of variance or the non-parametric Kruskal-Wallis test were used for continuous variables and Fisher’s Exact test or Pearson’s chi-squared test was used for categorical factors.Results:There was no difference in themean age between the two groups;however patients in the Study group had lower platelet count(P=0.005)as well as higher Model for End-Stage Liver disease(MELD)scores(P<0.001).Also,patients in the Study group had increased PSC severity as determined by Mayo PSC Risk Scores(1.50 vs.0.20)(P=0.001).Total bilirubin levels were higher in the Study group(2.3 vs.0.8mg/dL)(P=0.011).Comparing the post-operative complication rates without adjusting for disease severity,the Study group hadmore wound infections(P=0.034),more wound dehiscence(P=0.022),and a higher re-admission rate within 30 days(P=0.032);however,the post-operativemortality was not significantly different.Conclusion:Patients with PSC and UC who underwent TIPS prior to colectomy had higher rates of complications;however,this was probably due to the greater severity of cirrhosis and PSC in this population.展开更多
目的比较单独使用经颈内静脉肝内门体分流术(TIPS)与TIPS联合胃冠状静脉栓塞术(TIPS联合GCVE)治疗胃静脉曲张出血术后的再出血率与支架功能障碍发生率。确定胃冠状静脉栓塞术在治疗胃静脉曲张的价值。方法回顾性分析我院2011年1月~2016...目的比较单独使用经颈内静脉肝内门体分流术(TIPS)与TIPS联合胃冠状静脉栓塞术(TIPS联合GCVE)治疗胃静脉曲张出血术后的再出血率与支架功能障碍发生率。确定胃冠状静脉栓塞术在治疗胃静脉曲张的价值。方法回顾性分析我院2011年1月~2016年12月期间使用TIPS或TIPS联合GCVE治疗的143例胃静脉曲张出血的患者(其中TIPS组64例、TIPS联合GCVE组79例)。术后随访1年,采用Kaplan-Meier法比较两组间术后再出血率和生存率,采用Log-rank检验比较两组间生存曲线差异,生存时间以月为单位。结果单纯TIPS组与TIPS+GCVE组手术前后平均脉压差分别为11.57±0.92、17.35±1.08 cm H2O(P<0.01)。术后支架功能障碍率分别为4.77%、1.85%(P=0.82)。TIPS组与TIPS联合GCVE组术后1年累计生存率分别为85.94%、91.14%(P=0.32);TIPS组与TIPS联合GCVE组术后1年累计胃静脉曲张再出血率分别为28.12%、15.19%(P=0.048)。结论 TIPS联合GCVE治疗胃静脉曲张出血的术后1年累计生存率与单纯TIPS组无统计学差异,但TIPS联合GCVE组在术后降低门静脉压力与预防术后胃静脉曲张再出血更优于单纯TIPS组。展开更多
基金funded by the National Natural Science Foundation of China(81873917)。
文摘We report two cases of hepatic encephalopathy caused by molecular targeted drugs after the Transjugular intrahepatic portosystemic shunt(TIPS)procedure in our center.The liver toxicities and anti-angiogenic effects induced by targeted drugs may generate an imbalance in ammonia metabolism,elevating blood ammonia levels.TIPS diverts partial blood supply from the liver,aggravates liver impairment,and shunts ammonia-rich blood from the intestine into the systemic circulation.These may be the mechanisms leading to hepatic encephalopathy caused by molecular targeted drugs following TIPS.When clinicians choose molecular targeted therapy as the second or third targeted therapy for patients who have undergone TIPS,the consequence of drug-induced hepatic encephalopathy should also be considered.
文摘Background and aims:The present treatment goal of the transjugular intrahepatic portosystemic shunt(TIPS)is a portosystemic pressure gradient of12 mmHg or its reduction by>50%.This study relates the stent diameter to the reduction of the pressure gradient and attempts to predict the appropriate stent diameter necessary to reach the treatment goal.Methods:Pressure response,super response,and poor response were investigated in 208 de-novo TIPS patients and defined as post-TIPS gradients between>6 and 12 mmHg,6 mmHg,or not reaching the goal(>12 mmHg,reduction<50%),respectively.Pressures were related to the smallest stent diameters measured by planimetry of the radiographic image.Results:Responders(65%),super responders(26%),or poor responders(9%)had comparable stent diameters of 7.21.0 mm,but different post-TIPS gradients(9.71.9 mmHg,4.51.5 mmHg,and 14.21.4 mmHg,p<0.001),relative reduction of pre-TIPS gradients(51.711.4%,73.611.1%,and 34.09.1%,p<0.001),and specific reduction per mm of stent diameter(7.52.0%/mm,10.12.0%/mm,and 4.81.4%/mm,p<0.001).Prediction of the stent diameter required to reach response was not possible.Only two super responders had a stent diameter of<6 mm.Super and poor responders differed by the increase in the right atrial pressure(+5.0 mmHg vs.+3.1 mmHg,p=0.026)and reduction in the portal vein pressure(-8.6 mmHg vs.-4.6 mmHg,p<0.001).Conclusion:Most patients reached the treatment goal with stent diameters of<8 mm.Overtreatment(super response,gradient ≤6 mmHg)can be prevented by stent diameters as small as 6 mm.The individual response was not related to the stent diameter and not predictable.Cardiac dysfunction may play an important role by its effect on the right atrial(preload)and portal pressure(afterload).
文摘Transjugular intrahepatic portosystemic stent‐shunt(TIPS)was first reported in 1989 as a nonsurgical percutaneous method for treating patients suffering from severe end‐stage portal hypertension symptoms with Child's stage C metabolic status at Freiburg University Hospital in Germany.1 Since then,TIPS has become a unique percutaneous technique for treating portal hypertension,and it has spread throughout the world.In the early 1990s,medical standards in China lagged far behind Western countries,and interventional radiology(IR)depended heavily on imported medical instruments.During that period,IR doctors and scientists who received training abroad came back to China and began to use stenting techniques at a time when imported stent products were extremely scarce.Dr.Ke Xu,who received IR training in Japan in the late 1980s,treated a male patient with cirrhosis combined with repeated hematemesis with TIPS in the First Hospital of China Medical University in June 1992,which was certified the first case of TIPS in China(Figure 1A).
文摘Background and Aim:Gastric varices are associated with high mortality.There have been conflicting reports on whether endoscopic treatment with cyanoacrylate or the placement of a transjugular intrahepatic portosystemic shunt(TIPS)is more effective in the treatment of gastric varices.We compared the outcomes of patients treated with cyanoacrylate glue or TIPS for the management of acute gastric variceal bleeding.Methods:The study was designed as a retrospective cohort analysis of patients undergoing either TIPS or endoscopic treatment with cyanoacrylate for acute gastric variceal bleeding at our institution from 2001 to 2011.Primary compared to studied between the two treatment modalities were the short-term treatment outcomes,including re-bleeding within 30 days,length of hospital stay and in-hospital mortality.Kaplan-Meier survival analysis was performed to assess factors associated with in-hospital mortality.Results:A total of 169 patients were included in the analysis.The TIPS arm contained 140 patients and the cyanoacrylate arm contained 29 patients.There was no evidence to suggest any significant differences in demographics or disease severity.There were no differences between the TIPS arm and the cyanoacrylate armtwo groups in treatment outcomes including re-bleeding within 30 days(17.4%vs.17.2%;P=0.98),median length of stay in the hospital(4.5 days vs.6.0 days;P紏0.35)or in-hospital mortality(9.0%vs.11.1%;P=0.74).In-hospital mortality was evaluated for 149 patients and lower albumin(P=0.015),higher MELD score(P<0.001),higher CTP score(P=0.005)and bleeding(P=0.008)were all significantly associated with in-hospital death.Conclusion:These findings suggest that both treatments are equally effective.Cyanoacrylate offers a safe,effective alternative to TIPS for gastric varices,and physician may choose the best therapy for each patient,factoring in the availability of TIPS or cyanoacrylate,the individual patient’s presentation,and cost.
基金National Natural Science Foundation of China,Grant/Award Number:81873917。
文摘Patient prognosis after transjugular intrahepatic portosystemic shunt(TIPS)placement is relatively poor and highly heterogeneous;therefore,a prognostic scoring system is essential for survival prediction and risk stratification.Conventional scores include the Child–Turcotte–Pugh(CTP)and model for end‐stage liver disease(MELD)scores.The CTP score was created empirically and displayed a high correlation with post‐TIPS survival.However,the inclusion of subjective parameters and the use of discrete cut‐offs limit its utility.The advantages of the MELD score include its statistical validation and objective and readily available predictors that contribute to its broad application in clinical practice to predict post‐TIPS outcomes.In addition,multiple modifications of the MELD score,by incorporating additional predictors(e.g.,MELD‐Sodium and MELD‐Sarcopenia scores),adjusting coefficients(recalibrated MELD score),or combined(MELD 3.0),have been proposed to improve the prognostic ability of the standard MELD score.Despite several updates to conventional scores,a prognostic score has been proposed(based on contemporary data)specifically for outcome prediction after TIPS placement.However,this novel score(the Freiburg index of post‐TIPS survival,FIPS)exhibited inconsistent discrimination in external validation studies,and its superiority over conventional scores remains undetermined.Additionally,several tools display potential for application in specific TIPS indications(e.g.,bilirubin‐platelet grade for refractory ascites),and biomarkers of systemic inflammation,nutritional status,liver disease progression,and cardiac decompensation may provide additional value,but require further validation.Future studies should consider the effect of TIPS placement when exploring predictors,as TIPS is a pathophysiological approach that substantially alters systemic hemodynamics and ameliorates bacterial translocation and malnutrition.
文摘Objective:Primary sclerosing cholangitis(PSC)occurs in approximately 5%of patients with ulcerative colitis(UC).The risk of colon cancer is higher in patients undergoing colectomy,who have simultaneous PSC&UC.Our aim was to study the impact,in terms of post-colectomy survival and complications,of transjugular intrahepatic portosystemic shunt(TIPS)before colectomy in these patients.Methods:In this retrospective,case-control study,information was obtained on demographics,disease characteristics,TIPS characteristics,and post-colectomy complications.Nine patients with PSC and UC who underwent TIPS prior to colectomy(the Study group)and 37 patients with PSC and UC who underwent only colectomy without TIPS(the Control group)were included.Either an analysis of variance or the non-parametric Kruskal-Wallis test were used for continuous variables and Fisher’s Exact test or Pearson’s chi-squared test was used for categorical factors.Results:There was no difference in themean age between the two groups;however patients in the Study group had lower platelet count(P=0.005)as well as higher Model for End-Stage Liver disease(MELD)scores(P<0.001).Also,patients in the Study group had increased PSC severity as determined by Mayo PSC Risk Scores(1.50 vs.0.20)(P=0.001).Total bilirubin levels were higher in the Study group(2.3 vs.0.8mg/dL)(P=0.011).Comparing the post-operative complication rates without adjusting for disease severity,the Study group hadmore wound infections(P=0.034),more wound dehiscence(P=0.022),and a higher re-admission rate within 30 days(P=0.032);however,the post-operativemortality was not significantly different.Conclusion:Patients with PSC and UC who underwent TIPS prior to colectomy had higher rates of complications;however,this was probably due to the greater severity of cirrhosis and PSC in this population.
文摘目的比较单独使用经颈内静脉肝内门体分流术(TIPS)与TIPS联合胃冠状静脉栓塞术(TIPS联合GCVE)治疗胃静脉曲张出血术后的再出血率与支架功能障碍发生率。确定胃冠状静脉栓塞术在治疗胃静脉曲张的价值。方法回顾性分析我院2011年1月~2016年12月期间使用TIPS或TIPS联合GCVE治疗的143例胃静脉曲张出血的患者(其中TIPS组64例、TIPS联合GCVE组79例)。术后随访1年,采用Kaplan-Meier法比较两组间术后再出血率和生存率,采用Log-rank检验比较两组间生存曲线差异,生存时间以月为单位。结果单纯TIPS组与TIPS+GCVE组手术前后平均脉压差分别为11.57±0.92、17.35±1.08 cm H2O(P<0.01)。术后支架功能障碍率分别为4.77%、1.85%(P=0.82)。TIPS组与TIPS联合GCVE组术后1年累计生存率分别为85.94%、91.14%(P=0.32);TIPS组与TIPS联合GCVE组术后1年累计胃静脉曲张再出血率分别为28.12%、15.19%(P=0.048)。结论 TIPS联合GCVE治疗胃静脉曲张出血的术后1年累计生存率与单纯TIPS组无统计学差异,但TIPS联合GCVE组在术后降低门静脉压力与预防术后胃静脉曲张再出血更优于单纯TIPS组。
