经颈静脉肝内门体分流术治疗肝硬化门静脉高压患者的血清胆红素变化趋势研究
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摘要
目的探讨经颈静脉肝内门体分流术(transjugular intrahepatic portosystemic shunt,TIPS)治疗前后肝硬化门静脉高压患者的血清胆红素变化趋势。方法回顾性收集2016年10月—2018年6月行TIPS治疗的肝硬化门静脉高压患者术前和术后(术后1周、1个月、3个月、6个月)的肝功能、术前术后门静脉压力,并获得患者Child-Pugh评分、终末期肝病模型评分(model for end-stage liver disease,MELD)及白蛋白-胆红素评分(albumin-bilirubin grade,ALBI)。统计学分析中,计量资料采用配对t检验,5个时间点的胆红素变换后采用自身前后对比重复测量的方差分析,等级资料采用Wilcoxon符号秩检验。结果最终共纳入60例患者。患者TIPS术前和术后门静脉压力分别为(27.86±2.53)、(17.22±2.33)mm Hg(1 mm Hg=0.133 kPa),差异有统计学意义(P<0.05)。术前、术后1周、术后1个月、术后3个月、术后6个月的血清总胆红素(total bilirubin,TBIL)数据对数变换后[lg(TBIL)]分别为(1.27±0.23)、(1.44±0.21)、(1.51±0.20)、(1.56±0.22)、(1.48±0.19)lg(μmol/L),差异有统计学意义(P<0.001)。不同时间点的直接胆红素(direct bilirubin,DBIL)数据变换后[lg(DBIL)]分别为(0.90±0.26)、(1.14±0.24)、(1.18±0.25)、(1.21±0.28)、(1.08±0.21)lg(μmol/L),差异有统计学意义(P<0.001)。不同时间点的间接胆红素(indirect bilirubin,IBIL)数据变换后[lg(IBIL)]分别为(1.00±0.23)、(1.13±0.22)、(1.20±0.23)、(1.26±0.21)、(1.22±0.23)lg(μmol/L),差异有统计学意义(P<0.001)。患者术前的Child-Pugh、MELD、ALBI 3种肝脏储备功能评分与术后6个月的评分分别进行前后对比比较,差异均无统计学意义(P>0.05)。且患者术前的Child-Pugh和ALBI分级构成情况与术后6个月评分的构成情况前后对比比较,差异也均无统计学意义(P>0.05)。结论 TIPS可显著降低门静脉压力。TIPS术后一段时间内血清胆红素水平升高,但6个月内便出现下降好转。TIPS术并不影响患者术后6个月的肝脏储备功能。
Objective To investigate the trend of serum bilirubin in patients with liver cirrhosis before and after transjugular intrahepatic portosystemic shunt(TIPS). Methods The data of patients with cirrhotic portal hypertension who underwent TIPS between October 2016 and June 2018 were collected retrospectively, including liver function before and after surgery(1 week, 1 month, 3 months, and 6 months after surgery), preoperative and postoperative portal vein pressure, and the Child-Pugh scores, model for end-stage liver disease(MELD) scores, and albumin-bilirubin(ALBI)scores. Paired t-test was used for the statistical measurement data. The total bilirubin(TBIL), direct bilirubin(DBIL), and indirect bilirubin(IBIL) levels at five time points were analyzed by analysis of variance of repeated measurement data with its own before and after comparison, and Wilcoxon signed ranks test was used for the ordered data. Results A total of60 patients were included.The portal vein pressure was(27.86±2.53) mm Hg(1 mm Hg=0.133 kPa) before TIPS and(17.22±2.33) mm Hg after TIPS, and the difference was statistically significant(P<0.05). The common logarithm of the serum TBIL level [lg(TBIL)] before surgery and 1 week, 1 month, 3 months, and 6 months after surgery were(1.27±0.23),(1.44±0.21),(1.51±0.20),(1.56±0.22),(1.48±0.19) lg(μmol/L), respectively, and the difference was statistically significant(P<0.001). The common logarithm of the serum DBIL level [lg(DBIL)] at the five time periods were(0.90±0.26),(1.14±0.24),(1.18±0.25),(1.21±0.28),(1.08±0.21) lg(μmol/L), respectively, and the difference was statistically significant(P<0.001). The common logarithm of the serum IBIL level [lg(IBIL)] at the five time periods were(1.00±0.23),(1.13±0.22),(1.20±0.23),(1.26±0.21),(1.22±0.23) lg(μmol/L), respectively, and the difference was statistically significant(P<0.001). There were no statistically significant differences in the three liver reserve function scores(Child-Pugh, MELD,and ALBI, respectively) before and six months after operation(P>0.05). The differences in the composition of Child-Pugh and ALBI before and after surgery were not statistically significant(P>0.05). Conclusions TIPS has a significant effect on reducing portal hypertension. Serum bilirubin levels continue to increase during a period after TIPS, but begin to decrease within 6 months.
Objective To investigate the trend of serum bilirubin in patients with liver cirrhosis before and after transjugular intrahepatic portosystemic shunt(TIPS). Methods The data of patients with cirrhotic portal hypertension who underwent TIPS between October 2016 and June 2018 were collected retrospectively, including liver function before and after surgery(1 week, 1 month, 3 months, and 6 months after surgery), preoperative and postoperative portal vein pressure, and the Child-Pugh scores, model for end-stage liver disease(MELD) scores, and albumin-bilirubin(ALBI)scores. Paired t-test was used for the statistical measurement data. The total bilirubin(TBIL), direct bilirubin(DBIL), and indirect bilirubin(IBIL) levels at five time points were analyzed by analysis of variance of repeated measurement data with its own before and after comparison, and Wilcoxon signed ranks test was used for the ordered data. Results A total of60 patients were included.The portal vein pressure was(27.86±2.53) mm Hg(1 mm Hg=0.133 kPa) before TIPS and(17.22±2.33) mm Hg after TIPS, and the difference was statistically significant(P<0.05). The common logarithm of the serum TBIL level [lg(TBIL)] before surgery and 1 week, 1 month, 3 months, and 6 months after surgery were(1.27±0.23),(1.44±0.21),(1.51±0.20),(1.56±0.22),(1.48±0.19) lg(μmol/L), respectively, and the difference was statistically significant(P<0.001). The common logarithm of the serum DBIL level [lg(DBIL)] at the five time periods were(0.90±0.26),(1.14±0.24),(1.18±0.25),(1.21±0.28),(1.08±0.21) lg(μmol/L), respectively, and the difference was statistically significant(P<0.001). The common logarithm of the serum IBIL level [lg(IBIL)] at the five time periods were(1.00±0.23),(1.13±0.22),(1.20±0.23),(1.26±0.21),(1.22±0.23) lg(μmol/L), respectively, and the difference was statistically significant(P<0.001). There were no statistically significant differences in the three liver reserve function scores(Child-Pugh, MELD,and ALBI, respectively) before and six months after operation(P>0.05). The differences in the composition of Child-Pugh and ALBI before and after surgery were not statistically significant(P>0.05). Conclusions TIPS has a significant effect on reducing portal hypertension. Serum bilirubin levels continue to increase during a period after TIPS, but begin to decrease within 6 months.
引文
1Qin JP, Jiang MD, Tang W, et al. Clinical effects and complications of TIPS for portal hypertension due to cirrhosis:a single center.World J Gastroenterol, 2013, 19(44):8085-8092.
2 Bucsics T, Schoder M, Goeschl N, et al. Re-bleeding rates and survival after early transjugular intrahepatic portosystemic shunt(TIPS)in clinical practice. Digest Liver Dis, 2017, 49(12):1360-1367.
3Munawwar A, Nidugala KS, Vinu M, et al. Transjugular intrahepatic portosystemic shunt through the strut of a previously placed stent:technical feasibility and long-term follow-up results.Cardiovasc Intervent Radiol, 2018, 41(11):1794-1798.
4 Shah RP, Sze DY. Complications during transjugular intrahepatic portosystemic shunt creation. Tech Vasc Interv Radiol, 2016, 19(1):61-73.
5庹琳,汤善宏,曾维政,等.经颈静脉肝内门体分流术并发症的处理及预防措施.临床肝胆病杂志, 2016, 32(2):354-357.
6 Casadaban LC, Parvinian A, Couture PM, et al. Characterization of liver function parameter alterations after transjugular intrahepatic portosystemic shunt creation and association with early mortality.Ame J Roentgenol, 2014, 203(6):1363-1370.
7晏楠,白云飞,单志刚,等.经颈内静脉肝内门体静脉分流术后肝性脑病危险因素分析.临床误诊误治, 2015(7):39-43.
8 胡维林,罗小平,石小枫,等.经颈静脉肝内门体分流术治疗肝硬化顽固性腹水临床疗效及预后因素分析.重庆医科大学学报,2015(3):392-398.
9陈斯良,胡朋,林志鹏,等. TIPS术后短期总胆红素显著升高的相关因素分析及其对生存预后的影响.中华介入放射学电子杂志, 2018, 6(1):40-45.
10 Fonio P, Discalzi A, Calandri M, et al. Incidence of hepatic encephalopathy after transjugular intrahepatic portosystemic shunt(TIPS)according to its severity and temporal grading classification.Radiol Med, 2017, 122(9):713-721.
11Rajan DK, Haskal ZJ, Clark TW. Serum bilirubin and early mortality after transjugular intrahepatic portosystemic shunts:Results of a multivariate analysis. J Vasc Interv Radiol, 2002,13 (2 Pt 1):155-161.
12 Saxon RR, Mendel-Hartvig J, Corless CL, et al. Bile duct injury as a major cause of stenosis and occlusion in transjugular intrahepatic portosystemic shunts:comparative histopathologic analysis in humans and swine. J Vasc Interv Radiol, 1996, 7(4):487-497.
13宦徽,童欢,魏波,等.经颈静脉肝内门体静脉分流术联合胃左静脉栓塞术对肝硬化患者肝功能的影响.中华消化杂志, 2017,37(6):404-410.
14 中华医学会肝病学分会,中华医学会消化病学分会,中华医学会内镜学分会.肝硬化门静脉高压食管胃静脉曲张出血防治指南(2015).中华胃肠内镜电子杂志, 2015, 2(4):1-21.
15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.临床肝胆病杂志,2014, 30(3):210-213.
16中华医学会肝病学分会.肝硬化腹水及相关并发症的诊疗指南.中华肝脏病杂志, 2017, 25(9):664-677.
17 Pugh RN, Murray-Lyon IM, Dawson JL, et al. Transection of the oesophagus for bleeding oesophageal varices. Br J Surg, 1973,60(8):646-649.
18Kamath PS, Wiesner RH, Malinchoc M, et al. A model to predict survival in patients with end-stage liver disease. Hepatology, 2001,33(2):464-470.
19 Johnson PJ, Berhane S, Kagebayashi C, et al. Assessment of liver function in patients with hepatocellular carcinoma:a new evidence-based approach--The ALBI grade. J Clin Oncol, 2015,33(6):550-558.
20陈辉,吕勇,王秋和,等.经颈静脉肝内门体分流术专家共识.临床肝胆病杂志, 2017, 33(7):1218-1228.
21 陈晓平,汪建平.外科学. 8版.北京:人民卫生出版社, 2013:437.
22林佳媛.胆红素代谢及其调节的研究进展.复旦学报(医学版),2014, 41(3):405-411.
23 Akamatsu Y, Ohkohchi N, Seya K, et al. Analysis of bilirubin fraction in the bile for early diagnosis of acute rejection in living related liver transplantation. Tohoku J Exp Med, 1997, 181(1):145-154.
2 Bucsics T, Schoder M, Goeschl N, et al. Re-bleeding rates and survival after early transjugular intrahepatic portosystemic shunt(TIPS)in clinical practice. Digest Liver Dis, 2017, 49(12):1360-1367.
3Munawwar A, Nidugala KS, Vinu M, et al. Transjugular intrahepatic portosystemic shunt through the strut of a previously placed stent:technical feasibility and long-term follow-up results.Cardiovasc Intervent Radiol, 2018, 41(11):1794-1798.
4 Shah RP, Sze DY. Complications during transjugular intrahepatic portosystemic shunt creation. Tech Vasc Interv Radiol, 2016, 19(1):61-73.
5庹琳,汤善宏,曾维政,等.经颈静脉肝内门体分流术并发症的处理及预防措施.临床肝胆病杂志, 2016, 32(2):354-357.
6 Casadaban LC, Parvinian A, Couture PM, et al. Characterization of liver function parameter alterations after transjugular intrahepatic portosystemic shunt creation and association with early mortality.Ame J Roentgenol, 2014, 203(6):1363-1370.
7晏楠,白云飞,单志刚,等.经颈内静脉肝内门体静脉分流术后肝性脑病危险因素分析.临床误诊误治, 2015(7):39-43.
8 胡维林,罗小平,石小枫,等.经颈静脉肝内门体分流术治疗肝硬化顽固性腹水临床疗效及预后因素分析.重庆医科大学学报,2015(3):392-398.
9陈斯良,胡朋,林志鹏,等. TIPS术后短期总胆红素显著升高的相关因素分析及其对生存预后的影响.中华介入放射学电子杂志, 2018, 6(1):40-45.
10 Fonio P, Discalzi A, Calandri M, et al. Incidence of hepatic encephalopathy after transjugular intrahepatic portosystemic shunt(TIPS)according to its severity and temporal grading classification.Radiol Med, 2017, 122(9):713-721.
11Rajan DK, Haskal ZJ, Clark TW. Serum bilirubin and early mortality after transjugular intrahepatic portosystemic shunts:Results of a multivariate analysis. J Vasc Interv Radiol, 2002,13 (2 Pt 1):155-161.
12 Saxon RR, Mendel-Hartvig J, Corless CL, et al. Bile duct injury as a major cause of stenosis and occlusion in transjugular intrahepatic portosystemic shunts:comparative histopathologic analysis in humans and swine. J Vasc Interv Radiol, 1996, 7(4):487-497.
13宦徽,童欢,魏波,等.经颈静脉肝内门体静脉分流术联合胃左静脉栓塞术对肝硬化患者肝功能的影响.中华消化杂志, 2017,37(6):404-410.
14 中华医学会肝病学分会,中华医学会消化病学分会,中华医学会内镜学分会.肝硬化门静脉高压食管胃静脉曲张出血防治指南(2015).中华胃肠内镜电子杂志, 2015, 2(4):1-21.
15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.临床肝胆病杂志,2014, 30(3):210-213.
16中华医学会肝病学分会.肝硬化腹水及相关并发症的诊疗指南.中华肝脏病杂志, 2017, 25(9):664-677.
17 Pugh RN, Murray-Lyon IM, Dawson JL, et al. Transection of the oesophagus for bleeding oesophageal varices. Br J Surg, 1973,60(8):646-649.
18Kamath PS, Wiesner RH, Malinchoc M, et al. A model to predict survival in patients with end-stage liver disease. Hepatology, 2001,33(2):464-470.
19 Johnson PJ, Berhane S, Kagebayashi C, et al. Assessment of liver function in patients with hepatocellular carcinoma:a new evidence-based approach--The ALBI grade. J Clin Oncol, 2015,33(6):550-558.
20陈辉,吕勇,王秋和,等.经颈静脉肝内门体分流术专家共识.临床肝胆病杂志, 2017, 33(7):1218-1228.
21 陈晓平,汪建平.外科学. 8版.北京:人民卫生出版社, 2013:437.
22林佳媛.胆红素代谢及其调节的研究进展.复旦学报(医学版),2014, 41(3):405-411.
23 Akamatsu Y, Ohkohchi N, Seya K, et al. Analysis of bilirubin fraction in the bile for early diagnosis of acute rejection in living related liver transplantation. Tohoku J Exp Med, 1997, 181(1):145-154.