Percutaneous intrahepatic portosystemic shunt: its effects on hypersplenism

The aim of this study was to verify the early effects that the transjugular intrahepatic portosystemic shunt (TIPS) produces on thrombocytopenia and its possible relationship to portal pressure and the size of the spleen. A TIPS was placed in 24 cirrhotic patients (11 women and 13 men) with a mean age of 57.6 +/- 12.3 years. Prior to the test the platelets count, the size of the spleen and the portocaval gradient were determined. The same parameters were evaluated one day and one month afterwards. A significant increase was observed in then number of platelets following the placement of the prosthesis (87.6 +/- 55.2 vs 97 +/- 66.8 x 10(9)/l) (p < 0.05) which was maintained in the monthly control without achieving statistical significance (99.5 +/- 60.8 x 10(9)/l). A significant decrease was also observed in the size of the spleen from 156.7 +/- 28.7 mm during the previous control to 144.5 +/- 19.9 mm in the monthly control (p < 0.05). The portocaval gradient was significantly reduced following the procedure with the values being 23.25 +/- 3.86 mmHg prior to the TIPS, 10.29 +/- 3.84 mmHg in the immediate control and 10.37 +/- 4.81 mmHg at the one month control. A statistically significant correlation was observed between the size of the spleen and the number of platelets in both the previous control (r = 0.7264; p < 0.001) and in the monthly control (r = 0.5764; p < 0.05), between the size of the spleen and the portocaval gradient prior to the test (r = 0.5285; p < 0.05) and at one month (r = 0.7185; p < 0.01) and between the portocaval gradient and the number of platelets before the prosthesis (r = 0.5060; p < 0.05). TIPS may improve the thrombocytopenia in correlation with the decrease in portal pressure.     

Liver cell adenomas and portosystemic shunt

We report the case of a young man who developed multiple liver cell adenomas 13 years after a mesentericocaval shunt. Radiological findings did not provide diagnosis. Histological findings of two biopsied nodules were compatible with liver cell adenoma. Our patient had no known risk factors for liver cell adenomas. We discuss the hypothesis that disturbed hepatic vascularisation could promote the development of liver cell adenomas.     

Reducing risk of transjugular intrahepatic portosystemic shunt using ultrasound guided single needle pass

Delayed liver laceration following transjugular intrahepatic portosystemic shunt (TIPS) is a serious and likely underdiagnosed complication. It is however an important complication following TIPS, which remains one of the most technically challenging interventional procedures performed. In addition to laceration, a number of complications regarding bleeding and perforation are well described following TIPS procedures. We feel the adoption of techniques such as ours and that of other authors described in the literature using an ultrasoundguided percutaneous transhepatic approach with a small caliber needle provides a safer and less traumatic procedure and should reduce complications of bleeding and almost completely eliminate the risk of liver laceration. Our procedure was successfully performed under conscious sedation rather than general anaesthesia further reducing the overall procedural risk to the patient.     

经颈静脉门体静脉分流术精准技术与合理分流道的建立*

门静脉高压(portal hypertension,PH)是一组由门静脉压力持久增高引起的症候群,是肝硬化的主要并发症,可引起包括腹水、食管胃静脉曲张、肝性脑病和肝肾综合征等并发症。介入治疗是治疗门静脉高压的重要组成部分,其中经颈静脉肝内门体分流术(transjugular intrahepatic portosystemic shunt,TIPS)是介入治疗的核心技术,已广泛应用于临床,已使大量的门静脉高压患者受益[1-4]。尽管TIPS临床应用已经有30年左右的历史,但TIPS技术因其操作难度大,风险高,尤其是在缺乏经验的临床中心,在施行过程中出现问题时有发生。可发生患者原有的门静脉高压症状无改善或加重、原始分流道无功能、功能不全、分流道狭窄,更有甚者,发生心功能和肝功能衰竭、腹腔内出血,术中或术后短期内死亡等。这些问题的出现与许多因素有关,包括术前准备和评估不足、术中技术应用不当、术后随访管理不及时等。本文就TIPS术中穿刺技术精准性和建立合理的分流道的重要性进行了阐述。     

Body composition changes after transjugular intrahepatic portosystemic shunt in patients with cirrhosis

AIM:To investigate the effect of transjugular intra-hepatic porto-systemic shunt (TIPS) on malnutrition in portal hypertensive cirrhotic patients.METHODS: Twenty-one patients with liver cirrhosis and clinical indications for TIPS insertion were investigated before and 1, 4, 12, 52 wk after TIPS. For each patient we assayed body composition parameters [dry lean mass, fat mass, total body water (TBW)], routine liver and kidney function tests, and free fatty acids (FFA). Glucose and insulin were measured for t...     

经皮经肝肝内门体分流术后肝性脑病发病机制及其预防

随着经皮经肝肝内门体分流技术(transjugular intrahepatic portosystemic shunt,TIPS)的不断应用,其在食管胃底静脉曲张破裂出血和顽固性腹水的治疗方面,取得了突破性进展.然而,TIPS术后支架的狭窄闭塞和反复高发的肝性脑病(hepatic encephalopathy,HE)或称为分流性脑病(portal-systemic encephalopathy,PSE)成为困扰TIPS技术发展的两大难题,前者在近期带膜(血管)支架的大量应用后,得到极大的改善;后者始终未得到根本的解决,我们参阅了国内外的最新资料,在此进一步阐述TIPS术后另一难题-肝性脑病的发生情况.     

彩色多普勒超声诊断肝内门-体静脉分流价值探讨*

目的 探讨彩色多普勒超声检查肝内门-体静脉分流（IPSVS）的特征及诊断价值。方法 使用Philips IE33或GE LOGIQ9彩色多普勒超声诊断仪（凸阵探头,频率3.5～5.0 MHz）检查14例IPSVS患者,总结其肝脏超声图像特征及临床资料。所有患者经行多层螺旋CT检查并诊断为IPSVS。结果 在14例存在肝内门静脉分支与体循环静脉分支直接交通者中,男6例,女8例,年龄43～70岁; 1例为结肠癌并发肝内多发转移,2例为肝功能异常,8例为非肝脏疾病就诊的患者, 3例为乙型肝炎肝硬化;本组病变位于右肝12例（85.7%）,明显多于左肝2例[14.3%,P＜0.01];按Park分型,Ⅱ型5例（35.7%）,Ⅲ型9例（64.3%）;超声表现为肝内囊状或迂曲管道状无回声,与门静脉、肝静脉相通,彩色多普勒显示其内为红蓝两色交替或迂曲的血流信号,血流方向为从门静脉至肝静脉。结论 彩色多普勒超声能够敏感地发现异常血流并可测定血流方向、流速、流量,是IPSVS的首选诊断方法。     

Transjugular intrahepatic portosystemic shunt is associated with significant changes in mitral inflow parameters

Introduction. Liver cirrhosis is associated with hyperdynamic circulation which can result in heart failure. Transjugular intrahepatic portosystemic shunt (TIPS) due to increase of cardiac output is a stressful stimulus for cardiovascular system. Therefore, new methods for early detection of heart failure are needed. Transmitral flow is a marker of diastolic dysfunction.Aim. To analyze short- and long-term effect of TIPS procedure on transmitral flow.Material and Methods. 55 patients (38 men and 17 women, 55.6 ± 8.9 years) with liver cirrhosis treated with TIPS were enrolled in the study. Echocardiography was performed before, 24 h, 7, 30 and 180 days after the procedure. During 6 month follow up 22 patients died.Results. Left ventricle end-diastolic diameter was increasing during the follow-up [baseline: 47 (44.7–51.2) mm, day 7: 50 (46.5–51.3) mm, p < 0.05; day 30: 49.5 (46.7–55.2) mm, p < 0.01; 6 months: 52.5 (48.3–55.2) mm, p < 0.01)]. The peak early filling velocity (E) was significantly increasing [before: 75.5 (60.5–87.3) cm/s, 24 h: 88 (74.3–109.7), p < 0.01; day 7: 89 (81.5–105) p < 0.01; 1 month: 94 (82.7–108.5) p < 0.01; 6 month: 91 (80.1–120.2) p < 0.01]. Peak late atrial filling velocity (A) significantly increased within 24 h after the procedure: 85.1 (76.2–99.5) vs. 91.2 (81.5–104.5) cm/s, p < 0.05. The E/A ratio was increasing during the follow up (baseline: 0.88, 24 h after: 0.89, 1 week: 1.0, 30 days: 1.13, 6 month: 1.06 p < 0.01).Conclusion. Hemodynamic changes following TIPS procedure can be monitored using echocardiography. Transmitral flow analysis can serve as a useful tool for evaluating of diastolic function in these patients.     

Effect of transjugular portosystemic shunt on insulin resistance

Patients with cirrhosis of the liver suffer from hyperinsulinaemia and a certain degree of insulin resistance. More frequently than in the rest of the population they have diabetes. Transjugular intrahepatic portosystemic shunts (TIPS) as a therapeutic method in complications of portal hypertension lead to rapid haemodynamic changes in the liver. The objective of the submitted work was to assess whether TIPS has an impact on insulinaemia and whether it influences insulin resistance in patients with cirrhosis of the liver. GROUP AND METHODS: The authors evaluated a group of 22 patients with cirrhosis of the liver (10 diabetics and 12 subjects without diabetes) indicated for TIPS. They investigated the insulin and C-peptide concentration in blood obtained by catheterization from the hepatic and portal vein before and after TIPS and in the peripheral blood before TIPS, 1 hour, 1 day, 1 week and 1 month after TIPS. The insulin resistance was examined by the method of the hyperinsulin euglycaemic clamp (HEC) before TIPS, 1 day, 1 week, and 1 month after TIPS. The levels of C-peptide and insulin were assessed by the IRMA method. The blood sugar level in HEC was measured by means of a Hemocue apparatus. The results were evaluated by the non-parametric Wilcoxon test for two dependent samples. RESULTS: Both groups (diabetics and non-diabetics) were comparable as to age, sex, etiology of liver cirrhosis and indication for TIPS. After introduction of TIPS a change of insulin clearance occurred (p = 0.01) and a change of the insulin level in the hepatic vein immediately after TIPS (p = 0.02). Insulin clearance before TIPS was 37-90% (median 54%) and after TIPS it declined to 0-79% (median 38%) (p = 0.01). Already 1 hour after the operation the authors observed a rise of the insulin level in peripheral blood as compared with baseline values (p = 0.002). Statistically significant hyperinsulinaemia persisted one month after TIPS (p = 0.005). Values of C-peptide did not change significantly in time, neither in the hepatic vein nor in the peripheral blood. On examination of IR no statistically significant changes occurred after TIPS. On evaluation of different groups of diabetics and non-diabetics the IR was more marked in patients with DM (mean M = 1.7 mg/kg/min.) than in patients without DM (3.7 mg/kg/min.) (p = 0.03). The authors did not record significant changes of IR in time in different groups. Compensation of DM was not influenced by TIPS. The fasting blood sugar levels before TIPS and 1 month after TIPS were comparable. CONCLUSION: After TIPS a rise of the insulin level in peripheral blood occurred due to the reduced insulin clearance in the liver. Despite hyperinsulinaemia which persisted for one month after the operation, the insulin resistance did not deteriorate. Compensation of diabetes was not affected by TIPS.     

Clinical experience of transjugular intrahepatic portosystemic shunt (TIPS) and its effects on systemic hemodynamics

We performed TIPS (transjugular intrahepatic portosystemic shunt) in patients with intractable esophageal varices accompanied by repeated hematemesis or with refractory ascites for the purpose of portal venous decompression, and successfully obtained complete elimination of esophageal varices or a marked decrease in ascites. While TIPS caused no particular variations in mean blood pressure or heart rate, cardiac output increased markedly on the 2nd and 3rd postoperative days before declining on the 5th postoperative day. Along with this, right atrial pressure, pulmonary arterial pressure and pulmonary capillary wedge pressure also increased transiently. TIPS has the potential to become an established effectual therapy for intractable esophageal varices and refractory ascites. However, careful attention should be paid to its hemodynamic effects, including the occurrence of cardiac failure.     

经颈静脉肝内门体分流术的禁忌证及并发症

门静脉高压症(portal hypertention,PH)是由门静脉压力增高引起的一组症候群,主要临床表现有脾脏肿大、门腔侧支循环形成及腹水.各种原因引起的肝硬化是PH最主要的病因,约占PH病因的90%以上.     

Effects of different stent configurations on shunt failure and hepatic encephalopathy after transjugular intrahepatic portosystemic shunt

正Objective To compare the effects of different stent configurations on shunt failure,hepatic encephalopathy,and hepatic myelopathy after transjugular intrahepatic portosystemic shunt(TIPS).Methods From March 2014 to June 2015,the clinical data of 73 hospitalized patients who met the inclusion and exclusion criteria,and     

经颈静脉肝内门体分流术研究进展及其在肝硬化门静脉高压治疗中的应用

近年来,随着基础研究及临床应用的进步,经颈静脉肝内门体分流术(TIPS)的成功率明显提高,支架再狭窄率及术后肝性脑病的发生率亦得到控制。结合笔者临床实践及国内外大会热点,就TIPS相关技术进展及其在肝硬化中的应用进行介绍,主要包括TIPS穿刺辅助技术、TIPS支架、TIPS相关肝性脑病及防治以及TIPS适应证和禁忌证、TIPS在肝硬化中解决的问题、肝硬化食管胃底静脉曲张破裂出血治疗中TIPS相对于其他治疗方法的优缺点。以期为TIPS更好的发展作一点贡献,让更多肝硬化患者获益。