经颈静脉肝内门体分流术治疗肝硬化门静脉高压症临床研究
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摘要
目的探讨经颈静脉肝内门体分流术(TIPS)治疗肝硬化门静脉高压症患者的疗效,并总结术中操作关键点,以指导临床治疗。方法 2012年3月～2017年1月诊治的147例肝硬化门静脉高压症患者,术前行肝脏增强CT和肝静脉-门静脉血管CT三维重建,再行TIPS治疗。结果 147例患者均经右颈静脉入路穿刺,操作成功146例(99.3%);术中发生穿刺胆管、胆囊、肝动脉和肝包膜者分别为5例(3.4%)、2例(1.4%)、4例(2.7%)和8例(5.5%);2例(1.4%)发生异位栓塞;术前患者干质量(13.0±2.1) kg,空腹血糖(6.4±1.0) mmol/L,空腹胰岛素(20.2±9.3) m U/L,白蛋白(37.4±5.0) g/L,肌酐(59.2±15.9)μmol/L,尿素(5.1±1.6) mmol/L,总胆红素(18.6±5.0)μmol/L,血氨(66.8±24.3)μmol/L;术后3个月,上述指标分别为(15.4±3.2) kg、(5.8±1.4) mmol/L、(15.3±3.3) m U/L、(34.8±3.6) g/L、(58.5±10.9)μmol/L、(4.1±1.6) mmol/L、(27.3±7.2)μmol/L、(70.1±34.4)μmol/L,即术后门静脉压明显下降,干质量、总胆红素水平明显上升,空腹血糖、空腹胰岛素、白蛋白、尿素水平明显下降,差异有统计学意义(P<0.05);随访12个月,发生支架狭窄31例(21.2%),肝性脑病25例(17.1%)。结论 TIPS是治疗肝硬化门静脉高压症的可靠方法。手术的重点在于精确的穿刺定位,术前行CT检查和肝静脉-门静脉血管三维重建、术中行门静脉造影有助于保证穿刺操作的成功。
Objective To investigate the role of transjugular intrahepatic portosystemic shunt(TIPS) in the treatment of cirrhotics with portal hypertension. Methods A retrospective analysis was made on 147 patients with liver cirrhosis and portal hypertension,and all the patients received TIPS between March 2012 and January 2017.The patients received hepatic CT check-up and three-dimensional reconstruction of hepatic vein and portal vein was made. Results All the 147 patients were treated with TIPS by the right jugular vein approach,and 146 cases(99.3%) were successfully operated. Intraoperative punctures in bile duct,gallbladder,hepatic artery and liver capsule were 5 cases(3.4%),2 cases(1.4%),4 cases(2.7%) and 8 cases(5.5%),whereas no abdominal or bile duct bleeding occurred;ectopic embolism occurred in 2 cases(1.4%);the preoperative dry weight was(13.0±2.1)kg,fasting blood glucose was(6.4±1.0) mmol/L,fasting insulin levels was(20.2±9.3) m U/L,albumin was(37.4±5.0) g/L,creatinine was(59.2±15.9) μmol/L,urea was(5.1±1.6) mmol/L,total bilirubin was(18.6±5.0) μmol/L,blood ammonia was(66.8±24.3) μmol/L,while at the end of 3 months after TIPS,these indexes were(15.4±3.2)kg,(5.8±1.4) mmol/L,(15.3±3.3) mU/L,(34.8±3.6) g/L,(58.5±10.9) μmol/L,(4.1±1.6) mmol/L,(27.3±7.2) μmol/L and(70.1 ±34.4) μmol/L,respectively,suggesting postoperative portal venous pressure significantly decreased,dry weight and total bilirubin levels significantly increased;within 12 months of follow-up,there were stent stenosis in 31 cases(21.2%) and hepatic encephalopathy in 25 cases(17.12%). Conclusion TIPS is a reliable method for treatment of liver cirrhosis with portal hypertension,which might effectively improve the patients' conditions. The key of the operation is the precise puncture,preoperative CT three-dimensional reconstruction of liver and hepatic vein and portal vein,and intraoperative portal vein angiography.
Objective To investigate the role of transjugular intrahepatic portosystemic shunt(TIPS) in the treatment of cirrhotics with portal hypertension. Methods A retrospective analysis was made on 147 patients with liver cirrhosis and portal hypertension,and all the patients received TIPS between March 2012 and January 2017.The patients received hepatic CT check-up and three-dimensional reconstruction of hepatic vein and portal vein was made. Results All the 147 patients were treated with TIPS by the right jugular vein approach,and 146 cases(99.3%) were successfully operated. Intraoperative punctures in bile duct,gallbladder,hepatic artery and liver capsule were 5 cases(3.4%),2 cases(1.4%),4 cases(2.7%) and 8 cases(5.5%),whereas no abdominal or bile duct bleeding occurred;ectopic embolism occurred in 2 cases(1.4%);the preoperative dry weight was(13.0±2.1)kg,fasting blood glucose was(6.4±1.0) mmol/L,fasting insulin levels was(20.2±9.3) m U/L,albumin was(37.4±5.0) g/L,creatinine was(59.2±15.9) μmol/L,urea was(5.1±1.6) mmol/L,total bilirubin was(18.6±5.0) μmol/L,blood ammonia was(66.8±24.3) μmol/L,while at the end of 3 months after TIPS,these indexes were(15.4±3.2)kg,(5.8±1.4) mmol/L,(15.3±3.3) mU/L,(34.8±3.6) g/L,(58.5±10.9) μmol/L,(4.1±1.6) mmol/L,(27.3±7.2) μmol/L and(70.1 ±34.4) μmol/L,respectively,suggesting postoperative portal venous pressure significantly decreased,dry weight and total bilirubin levels significantly increased;within 12 months of follow-up,there were stent stenosis in 31 cases(21.2%) and hepatic encephalopathy in 25 cases(17.12%). Conclusion TIPS is a reliable method for treatment of liver cirrhosis with portal hypertension,which might effectively improve the patients' conditions. The key of the operation is the precise puncture,preoperative CT three-dimensional reconstruction of liver and hepatic vein and portal vein,and intraoperative portal vein angiography.
引文
[1]Iwakiri Y.Pathophysiology of portal hypertension.Clin Liver Dis,2014,18(2):281-291.
[1]Lv Y,Fan D.Hepatopulmonary syndrome.Dig Dis Sci,2015,60(7):1914-1923.
[2]Patidar KR,Sydnor M,Sanyal AJ.Transjugular intrahepatic portosystemic shunt.Clin Liver Dis,2014,18(4):853-876.
[3]Parker R.Role of transjugular intrahepatic portosystemic shunt in the management of portal hypertension.Clin Liver Dis,2014,18(2):319-334.
[4]中华医学会消化病学分会消化介入学组.经颈静脉肝内门体静脉分流术治疗肝硬化门静脉高压共识意见.中华消化杂志,2014,34(1):210-213.
[5]Tsauo J,Weng N,Ma H,et al.Role of transjugular intrahepatic portosystemic shunts in the management of hepatopulmonary syndrome:A systemic literature review.J Vasc Interv Radiol,2015,26(9):1266-1271.
[6]Bettinger D,Knüppel E,Euringer W,et al.Efficacy and safety of transjugular intrahepatic portosystemic shunt(TIPSS)in 40patients with hepatocellular carcinoma.Aliment Pharmacol Ther,2015,41(1):126-136.
[7]陈斯良,赵剑波,陈勇,等.经颈静脉肝内门腔静脉分流术中覆膜支架与裸支架的不同放置方式对术后中长期疗效的影响.中华放射学杂志,2016,50(11):885-888.
[8]Copelan A,Kapoor B,Sands M.Transjugular intrahepatic portosystemic shunt:indications,contraindications,and patient workup.Semin Intervent Radiol,2014,31(3):235-242.
[9]Suhocki PV,Lungren MP,Kapoor B,et al.Transjugular intrahepatic portosystemic shunt complications:prevention and management.Semin Intervent Radiol,2015,32(2):123-132.
[10]倪其泓,张赟和,何敏,等.多排螺旋CT三维重建技术在肝门部胆管癌术前可切除性评估与手术规划中的应用.中华肝胆外科杂志,2016,22(7):489-490.
[11]Aghayev A,Ozbayrak M,Tatli S.Treatment of neovaginal variceal bleeding after transgender surgery with transjugular intrahepatic portosystemic shunt.J Vasc Interv Radiol,2015,26(5):762-763.
[12]Qin JP,Tang SH,Jiang MD,et al.Contrast enhanced computed tomography and reconstruction of hepatic vascular system for transjugular intrahepatic portal systemic shunt puncture path planning.World J Gastroenterol,2015,21(32):9623-9639.
[13]曹海霞,范建高.肝硬化患者营养评估及营养支持治疗.实用肝脏病杂志,2014,17(5):459-462.
[14]Goswami A,Bhargava N,Dadhich S,et al.Insulin resistance in euglycemic cirrhosis.Ann Gastroenterol,2014,27(3):237-243.
[15]Ishikawa T,Shiratsuki S,Matsuda T,et al.Occlusion of portosystemic shunts improves hyperinsulinemia due to insulin resistance in cirrhotic patients with portal hypertension.J Gastroenterol,2014,49(9):1333-1341.
[16]Qin J,Tang S,He Q,et al.Retrospective analysis of venograms of hepatic and portal veins:clinical implications for transjugular intrahepatic portosystemic shunt placement.Hepatogastroenterology,2014,61(133):1165-1169.
[1]Lv Y,Fan D.Hepatopulmonary syndrome.Dig Dis Sci,2015,60(7):1914-1923.
[2]Patidar KR,Sydnor M,Sanyal AJ.Transjugular intrahepatic portosystemic shunt.Clin Liver Dis,2014,18(4):853-876.
[3]Parker R.Role of transjugular intrahepatic portosystemic shunt in the management of portal hypertension.Clin Liver Dis,2014,18(2):319-334.
[4]中华医学会消化病学分会消化介入学组.经颈静脉肝内门体静脉分流术治疗肝硬化门静脉高压共识意见.中华消化杂志,2014,34(1):210-213.
[5]Tsauo J,Weng N,Ma H,et al.Role of transjugular intrahepatic portosystemic shunts in the management of hepatopulmonary syndrome:A systemic literature review.J Vasc Interv Radiol,2015,26(9):1266-1271.
[6]Bettinger D,Knüppel E,Euringer W,et al.Efficacy and safety of transjugular intrahepatic portosystemic shunt(TIPSS)in 40patients with hepatocellular carcinoma.Aliment Pharmacol Ther,2015,41(1):126-136.
[7]陈斯良,赵剑波,陈勇,等.经颈静脉肝内门腔静脉分流术中覆膜支架与裸支架的不同放置方式对术后中长期疗效的影响.中华放射学杂志,2016,50(11):885-888.
[8]Copelan A,Kapoor B,Sands M.Transjugular intrahepatic portosystemic shunt:indications,contraindications,and patient workup.Semin Intervent Radiol,2014,31(3):235-242.
[9]Suhocki PV,Lungren MP,Kapoor B,et al.Transjugular intrahepatic portosystemic shunt complications:prevention and management.Semin Intervent Radiol,2015,32(2):123-132.
[10]倪其泓,张赟和,何敏,等.多排螺旋CT三维重建技术在肝门部胆管癌术前可切除性评估与手术规划中的应用.中华肝胆外科杂志,2016,22(7):489-490.
[11]Aghayev A,Ozbayrak M,Tatli S.Treatment of neovaginal variceal bleeding after transgender surgery with transjugular intrahepatic portosystemic shunt.J Vasc Interv Radiol,2015,26(5):762-763.
[12]Qin JP,Tang SH,Jiang MD,et al.Contrast enhanced computed tomography and reconstruction of hepatic vascular system for transjugular intrahepatic portal systemic shunt puncture path planning.World J Gastroenterol,2015,21(32):9623-9639.
[13]曹海霞,范建高.肝硬化患者营养评估及营养支持治疗.实用肝脏病杂志,2014,17(5):459-462.
[14]Goswami A,Bhargava N,Dadhich S,et al.Insulin resistance in euglycemic cirrhosis.Ann Gastroenterol,2014,27(3):237-243.
[15]Ishikawa T,Shiratsuki S,Matsuda T,et al.Occlusion of portosystemic shunts improves hyperinsulinemia due to insulin resistance in cirrhotic patients with portal hypertension.J Gastroenterol,2014,49(9):1333-1341.
[16]Qin J,Tang S,He Q,et al.Retrospective analysis of venograms of hepatic and portal veins:clinical implications for transjugular intrahepatic portosystemic shunt placement.Hepatogastroenterology,2014,61(133):1165-1169.