经颈内静脉肝内门腔静脉分流术治疗门静脉高压伴食管胃底静脉曲张破裂出血的临床疗效
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摘要
目的分析采用经颈内静脉肝内门腔静脉分流术(Transjugular intrahepatic portosystemic stent shunt,Tipss)在治疗门静脉高压伴食管胃底静脉曲张致破裂出血的临床疗效,为临床在治疗该类患者时术式选择提供参考依据。方法以我院2015年8月至2017年8月收治的门静脉高压伴食管胃底静脉曲张破裂出血患者91例作为研究对象,分为Tipss组(43例)与内镜下套扎止血治疗组(48例)。比较两种术式对患者的临床疗效;比较患者肝脏功能生化指标,统计分析患者术后并发症种类及发生率。结果行Tipss术患者显效率显著高于对照组,差异有统计学意义(P<0. 05)。两组患者治疗后凝血指标血小板含量均显著增高,且Tipss组治疗后血小板显著高于对照组,凝血酶原时间低于对照组,差异有统计学意义(P<0. 05)。Tipss组谷丙转氨酶水平较治疗前差异无统计学意义(P>0. 05),而对照组含量较治疗前显著降低,差异有统计学意义(P<0. 05); Tipss组术后血氨值(NH_3)明显增高,且显著高于对照组术后,差异有统计学意义(P<0. 05)。两种术式术后局部黏膜坏死等轻度并发症发病率差异无统计学意义(P>0. 05),但Tipss组术后消化道出血、肝性脑病发病率显著高于对照组,差异有统计学意义(P<0. 05)。结论与一线疗法内镜下套扎术相比,Tipss术能更有效抑制食管胃底静脉曲张破裂出血,改善患者静脉曲张情况。但较易出现严重术后并发症,建议临床医生在应用时充分评估风险,做好预防和处理工作。
Objective To observe the clinicalefficacy of trans-jugular intrahepatic portosystemic stent shunt( TIPSS) on portal hypertension with esophagogastric variceal bleedingandprovide a referenceforoperation choosing in such patients.Methods 91 patients diagnosed with portal hypertension with esophageal varices bleeding from August 2015 to August 2017 in our hospital were enrolled.Participants were divided into TIPSS group( 43 cases) and endoscopic variceal ligation group( 48 cases).Clinical efficacyoftreatments、biochemical parameters of liver function、types and incident ratesof postoperative complications in two patient groups were compared.Results TIPSS group showed significantly higher effective rate than the endoscopic variceal ligationgroup( P<0. 05).Coagulation indexesandplatelet concentrations in both groups showed significant increases after treatment.Moreover,patients in the TIPSS group had higher platelet concentrations and shorter prothrombin time than those in the endoscopic variceal ligation group( P<0. 05).Blood ammonia levels( NH3) in patients of the TIPSS group were significantly increased after treatment and were markedly higher than those in the endoscopic variceal ligation group( P<0. 05).There was no significant difference in the occurrence of mild complications such as local mucosal necrosis( P>0. 05),butthe incident ratesofgastrointestinal hemorrhageandhepatic encephalopathy were significantly higher in the TIPSS group compared to the other group( P< 0. 05). Conclusion TISPPshowed higher efficacy than endoscopic variceal ligation in inhibiting esophageal variceal bleeding and improving the condition of varicose veins.What should be noticed is that there were higher rates of severe postoperative complications in TIPSS therapy,which alerts clinicians to fully assess the risks and make good preparation of prevention and emergencymeasures before its application.
Objective To observe the clinicalefficacy of trans-jugular intrahepatic portosystemic stent shunt( TIPSS) on portal hypertension with esophagogastric variceal bleedingandprovide a referenceforoperation choosing in such patients.Methods 91 patients diagnosed with portal hypertension with esophageal varices bleeding from August 2015 to August 2017 in our hospital were enrolled.Participants were divided into TIPSS group( 43 cases) and endoscopic variceal ligation group( 48 cases).Clinical efficacyoftreatments、biochemical parameters of liver function、types and incident ratesof postoperative complications in two patient groups were compared.Results TIPSS group showed significantly higher effective rate than the endoscopic variceal ligationgroup( P<0. 05).Coagulation indexesandplatelet concentrations in both groups showed significant increases after treatment.Moreover,patients in the TIPSS group had higher platelet concentrations and shorter prothrombin time than those in the endoscopic variceal ligation group( P<0. 05).Blood ammonia levels( NH3) in patients of the TIPSS group were significantly increased after treatment and were markedly higher than those in the endoscopic variceal ligation group( P<0. 05).There was no significant difference in the occurrence of mild complications such as local mucosal necrosis( P>0. 05),butthe incident ratesofgastrointestinal hemorrhageandhepatic encephalopathy were significantly higher in the TIPSS group compared to the other group( P< 0. 05). Conclusion TISPPshowed higher efficacy than endoscopic variceal ligation in inhibiting esophageal variceal bleeding and improving the condition of varicose veins.What should be noticed is that there were higher rates of severe postoperative complications in TIPSS therapy,which alerts clinicians to fully assess the risks and make good preparation of prevention and emergencymeasures before its application.
引文
[1]张静雯,时永全,韩英.肝硬化的治疗进展[J].临床肝胆病杂志,2015,31(3):465-468.
[2]贺加星,阴继凯,刘凡,等.肝硬化门静脉高压并发上消化道出血的相关危险因素分析[J].中国普通外科杂志,2015,4(1):127-130.
[3]陆伦根,李郑红.肝纤维化及肝硬化研究近况[J].临床肝胆病杂志,2013,29(5):321-323.
[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[J].临床肝胆病杂志,2014,34(1):210-213.
[5]中华医学会消化内镜学分会.食管胃静脉曲张内镜下诊断和治疗规范试行方案(2003年)[J].中华消化内镜杂志.2004,21(3):149-151.
[6]万思明.肝硬化门静脉高压并发上消化道出血的相关危险因素分析[J].系统医学,2018,3(2):50-52.
[7]中华医学会肝病学分会,中华医学会消化病学分会,中华医学会消化内镜学分会.肝硬化门静脉高压食管胃静脉曲张出血的防治指南[J].中华内科杂志,2016,55(1):57-72.
[8]朱庆曦,田霞,刘蒙,等.内镜下套扎联合组织胶注射治疗食管静脉曲张破裂出血的临床疗效[J].世界华人消化杂志,2016,24(13):2045-2050.
[9]周年兰,张明娟,王甦,等.内镜下套扎、硬化剂及组织胶注射治疗食管静脉曲张破裂出血的近期疗效观察[J].临床肝胆病杂志.2014,30(7):628-630.
[10]周光文,杨连粤.肝硬化门静脉高压症食管、胃底静脉曲张破裂出血诊治专家共识(2015)[J].中国实用外科杂志,2015,35(10):1086-1090.
[11]龚丽娟,曹建彪,刘杰.Tipss治疗食管胃底静脉曲张出血的护理[J].现代中西医结合杂志,2013,22(10):1121-1122.
[12]陈发玉,朱家胜.TIPSS治疗门静脉高压症进展[J].辽宁医学院学报,2011,32(6):557-559.
[13]张德智,王永亮,濮芸健,等.TIPSS术治疗肝硬化合并食管胃底静脉曲张破裂出血的效果[J].中国继续医学教育,2017,9(8):114-115.
[14]唐承薇,李肖.肝硬化门静脉高压治疗策略[J].中国实用内科杂志,2011,31(1):79-80.
[15]Gao Qinyi,Zhang Xitong Shu Qiang,et al.The preliminary studies on prevention of TIPSS shunt stenosis with 103Pd stents[J].Nuclear Science and Techniques,2004,15(5):14-15.
[2]贺加星,阴继凯,刘凡,等.肝硬化门静脉高压并发上消化道出血的相关危险因素分析[J].中国普通外科杂志,2015,4(1):127-130.
[3]陆伦根,李郑红.肝纤维化及肝硬化研究近况[J].临床肝胆病杂志,2013,29(5):321-323.
[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[J].临床肝胆病杂志,2014,34(1):210-213.
[5]中华医学会消化内镜学分会.食管胃静脉曲张内镜下诊断和治疗规范试行方案(2003年)[J].中华消化内镜杂志.2004,21(3):149-151.
[6]万思明.肝硬化门静脉高压并发上消化道出血的相关危险因素分析[J].系统医学,2018,3(2):50-52.
[7]中华医学会肝病学分会,中华医学会消化病学分会,中华医学会消化内镜学分会.肝硬化门静脉高压食管胃静脉曲张出血的防治指南[J].中华内科杂志,2016,55(1):57-72.
[8]朱庆曦,田霞,刘蒙,等.内镜下套扎联合组织胶注射治疗食管静脉曲张破裂出血的临床疗效[J].世界华人消化杂志,2016,24(13):2045-2050.
[9]周年兰,张明娟,王甦,等.内镜下套扎、硬化剂及组织胶注射治疗食管静脉曲张破裂出血的近期疗效观察[J].临床肝胆病杂志.2014,30(7):628-630.
[10]周光文,杨连粤.肝硬化门静脉高压症食管、胃底静脉曲张破裂出血诊治专家共识(2015)[J].中国实用外科杂志,2015,35(10):1086-1090.
[11]龚丽娟,曹建彪,刘杰.Tipss治疗食管胃底静脉曲张出血的护理[J].现代中西医结合杂志,2013,22(10):1121-1122.
[12]陈发玉,朱家胜.TIPSS治疗门静脉高压症进展[J].辽宁医学院学报,2011,32(6):557-559.
[13]张德智,王永亮,濮芸健,等.TIPSS术治疗肝硬化合并食管胃底静脉曲张破裂出血的效果[J].中国继续医学教育,2017,9(8):114-115.
[14]唐承薇,李肖.肝硬化门静脉高压治疗策略[J].中国实用内科杂志,2011,31(1):79-80.
[15]Gao Qinyi,Zhang Xitong Shu Qiang,et al.The preliminary studies on prevention of TIPSS shunt stenosis with 103Pd stents[J].Nuclear Science and Techniques,2004,15(5):14-15.