腹腔静脉分流术治疗肝硬化难治性腹水的临床初步评价

评价Ｄｅｎｖｅｒ管腹腔颈内静脉分流术 (ＰＶＳ)治疗肝硬化难治性腹水的效果。选择 10例肝硬化难治性腹水病人置Ｄｅｎｖｅｒ管行腹腔颈内静脉分流术。手术前后观察病人的体重、尿量、腹围、生化指标和凝血指标以及生活质量的改变。结果表明 ,术后所有病人体重较术前平均降低 2 .7ｋｇ(Ｐ <0 .0 1) ,腹围平均减少 11.7ｃｍ (Ｐ <0 .0 1) ,尿量平均增加 10 53.8ｍｌ/ｄ(Ｐ <0 .0 1) ,肌酐和尿素氮水平均有改善 (Ｐ <0 .0 5) ,且 9/ 10病人为明显改善。尽管白蛋白和肝功能无明显变化 ,但生活质量有改善。所有病人均有生化的ＤＩＣ指标异常 ,…     

Denver管腹腔静脉分流术的并发症及其处理

目的：分析Denver管腹腔静脉分流术（PVS）临床运用的并发症及其处理的效果。方法：回顾性分析20例行PVS术后患者的近远期并发症的类型和发生率，统计各项处理措施的效果和术后患者生存率。结果：共有29例次9类（12种）并发症发生，近期（＜1月）19例次，中远期（＞1月）10例次，1年堵管率为5％。共有13例（65％）患者出现并发症，9例（45％）为近期并发症，9例（65％）为中远期并发症，有4种并发症导致了随后患者的死亡。肝硬化难治性腹水者术后1年生存率为24％，生存期小于半年的主要影响因素是高龄和Child C级。与PVS术直接相关的死亡原因是败血症、上消化道出血和DIC。结论：Denver管PVS术后半数以上患者出现并发症，经积极处理后大多数近期并发症可以缓解，不少可积极预防，中远期并发症缓解率极低，部分可能原因是随访指导不够和不能及时治疗。只要合理选择患者，术前积极准备，改善置管技术，术后积极预防并发症，加强随访和及时治疗并发症，PVS在肝硬化难治性腹水及癌性腹水治疗中仍可发挥一定作用。     

抗病毒药联合Denver管治疗乙型肝炎肝硬化难治性腹水2例

核苷(酸)类抗病毒药运用于失代偿性乙型肝炎肝硬化,可明显改善预后,延缓或避免肝移植.但伴有难治性腹水的失代偿性乙型肝炎肝硬化患者,在药物有效抑制病毒的初期,临床改善相对滞后,不少患者未等到获益,即因腹腔感染、肝肾综合征等并发症死亡[1].我们对2例乙型肝炎肝硬化难治性腹水患者行抗病毒治疗的前后,联合Denver管腹腔静脉分流术(PVS)治疗腹水,使抗病毒效果充分发挥,获得4.5 ～ 5.5年长期生存的疗效,现报道如下.     

Denver管腹腔静脉分流术的围手术期处理分析

顽固性腹水又称难治性腹水,内科治疗困难.腹腔静脉转流(PVS)术是治疗顽固性腹水的外科手段,可明显增加尿量、降低体重、减小腹围、减少白蛋白输入量及提高生活质量[1-2],但术后并发症较多(>40%)[3],大多发生于围手术期,能否恰当处理是治疗成败的关键.     

腹水浓缩回输腹腔治疗肝硬化难治性腹水的效果评价

目的探讨腹水超滤浓缩回输腹腔在肝硬化难治性腹水治疗中的应用效果。方法对21例肝硬化难治性腹水患者在左下腹、右中腹进行腹腔穿刺,连接导管,通过滤过器在负压泵作用下形成超滤,浓缩后的腹水经静脉导管自右中腹回输入腹腔。结果超滤后患者体重下降,腹围缩小,尿量增加,血肌酐下降,总蛋白、白蛋白上升(P<0.05),补体C3浓度上升(P<0.01)。结论腹水超滤回输治疗肝硬化难治性腹水有效、安全、简便、副作用少。     

五皮饮加味联合腹水回输治疗肝硬化难治性腹水的临床观察

[目的]探讨五皮饮加味联合腹水超滤浓缩回输治疗肝硬化难治性腹水的疗效及安全性.[方法]选择肝硬化难治性腹水住院患者86例,随机分成2组,各43例,治疗组采用五皮饮加味联合腹水回输疗法,对照组采用单纯腹水回输疗法,腹水回输每2周1次,每次3 000～5 000 ml,疗程均为2个月,治疗后观察患者体重、腹围、尿量、血浆白蛋白、肝功能、腹水等变化.[结果]2组患者症状均明显好转,其中治疗组总有效率达81.39％,对照组为48.84％,2组比较差异有统计学意义(P＜0.05);治疗组患者肝功能、白蛋白、腹围、体重均明显改善,与对照组比较差异有统计学意义(P＜0.05).[结论]五皮饮加味联合腹水回输治疗肝硬化难治性腹水是安全、有效的方法,具有较好的疗效.     

Denver氏管法治疗顽固性腹水

目的评价Denver氏管置入术治疗顽固性腹水的临床效疗.方法回顾研究了经Denver氏管置入术治疗顽固性腹水病例13例结果13例顽固性腹水患者病因中肝硬化9例、Budd-Chiari综合征3例、肝动脉-门静脉瘘l例;手术前肝功能Child B级5例、C级8例,术后B转到C级1例,同级中好转4例、恶化3例;术后腹围下降3～29 cm,平均12.23±8.67 cm;生活指数较术前平均提高2 5.83±10.84,随访半年以上12例,最长达6年7个月,效果良好者8例.结论Denver氏管置入术是治疗顽固性腹水的良好方法,对治疗效果不佳者不失为一种较好选择.     

腹腔置管治疗顽固性腹水对血浆RAAS的影响

目的 探讨中心静脉导管腹腔置入术治疗顽固性腹水对肾素-血管紧张素Ⅱ-醛固酮系统(RAAS)的影响.方法 21例肝硬化顽固性腹水患者,经皮穿刺导丝引导法置入中心静脉导管,通过该导管隔日大量引流一次腹水,同时联合内科综合治疗,检测腹水引流前后肾素、血管紧张素Ⅱ和醛固酮水平及体重、腹围、尿量和肾功能.结果 所有患者感腹胀、纳差、呼吸困难症状均完全缓解或者部分缓解;置管治疗能迅速减少腹围,显效33.3%,总有效率达71.4%;治疗后腹围及体重显著低于治疗前,而肾功能有所恢复;并且血浆肾素、血管紧张素Ⅱ和醛固酮水平显著减低(P＜0.05);引流不畅3例(占14.3%),穿刺点腹水渗漏2例(占9.5%),无其他严重并发症.结论 中心静脉导管腹腔置入术联合内科综合治疗是肝硬化顽固性腹水的有效治疗方法,能迅速消除腹水,抑制RAAS系统活性,并发症少,安全可靠.     

麝黄膏脐敷治疗肝硬化难治性腹水临床研究

目的 :观察麝黄膏治疗肝硬化难治性腹水的疗效。方法 :选择肝硬化难治性腹水住院患者 ,治疗组 (32例 )采用基础治疗 +麝黄膏脐敷 ,对照组 (2 7例 )采用基础治疗 (包括保肝药物 ,利尿剂 ,白蛋白 ,抗生素等 )。观察治疗前后患者的体重、2 4 h尿量和尿电解质、肝功能以及血清一氧化氮 (NO)含量。彩色多普勒测量门脉血流量。结果 :治疗组总有效率为 84 .0 % ,对照组总有效率为 4 9.1%。治疗组治疗后体重、腹围明显下降、肝功能明显改善 ,2 4h的尿量增多。治疗组 NO含量、门脉血流量明显下降 (P <0 .0 5 ) ,而对照组无明显改善 (P >0 .0 5 )。结论 :麝黄膏脐敷对肝硬化难治性腹水有明显的治疗作用 ,比单纯基础治疗疗效高。     

通阴三阳灸治疗肝硬化腹水临床研究

目的:观察通阴三阳灸治疗乙型肝炎肝硬化腹水患者的临床疗效。方法:66例乙肝肝硬化腹水患者随机分为两组,各33例。对照组患者采用基础治疗,治疗组患者在此基础上加用通阴三阳灸法,1次/3d,3次为1个疗程,共治疗3个疗程。疗程结束后,观察两组患者治疗前后腹水、24h尿量、体重、腹围、肝功能(ALT、AST)、症状总积分变化情况。结果:3个疗程后两组患者在ALT、AST、腹围、体重、24h尿量、症状总积分指标上均较治疗前明显改善(P 0. 05),组间比较,差异有统计学意义(P 0. 05)。结论:通阴三阳灸疗法可加快患者腹水的消退,改善临床症状,提高其生活质量。     

Denver Peritoneovenous Shunting for Malignant or Cirrhotic Ascites: A Prospective Consecutive Series

A Denver peritoneovenous (PV) shunt was inserted in 54 consecutive patients for relief of malignant (24 patients) or cirrhotic (30) refractory ascites. The median age of both groups was 58 years, and the most frequent diagnoses were gastrointestinal (15) or ovarian (7) cancers and alcoholic cirrhosis (25). Median survival time was 1.7 and 3.5 months (range, 0.1–15.5 and 0.1–50.5), and the 1-month mortality 42% and 27%, respectively. Postoperative 24-h urinary output increased by 2–3 1, and the 1-week weight reduction was 8 and 11 kg, respectively, compared with before shunting. Complete shunt failure was encountered early in two patients, due to catheter malposition and clotting. Four more patients experienced transient failure, for an early dysfunction rate of 11%. A shunt-related operative mortality of 6% was caused by pulmonary oedema (two patients) and sepsis (one patient). Shunt malfunction intervened in almost half (6 of 14) of the cancer patients surviving 1 month but was relieved in all but 1. In 3 of 22 cirrhotic 1-month survivors, the Denver shunt had to be removed owing to clotting or sepsis (2 patients) or revised because of blockage. Seven patients with cirrhosis are alive a median of 18 months (range, 2–51) after PV shunt surgery. Side effects were detected in 22 patients (41%): thromboembolism (9 patients), sepsis (7), initially bleeding oesophageal varices (3), DIC syndrome (2), postoperative hepatic coma (2), ascitic leakage (2), and pulmonary oedema (2). Patients with gastrointestinal cancers or severe cardiac disease did not benefit from the procedure. A history of hepatic encephalopathy or a serum bilirubin level above about 100 μmol/l was a bad prognostic sign. We could confirm the reported considerable morbidity and mortality after PV shunting, but also its efficiency in certain cases. Careful patient selection and follow-up study, timing of operation, and adherence to technical details are mandatory to improve the results.     

Acute effects of peritoneovenous shunting on plasma atrial natriuretic peptide in cirrhotic patients with massive refractory ascites

Plasma immunoreactive alpha-human atrial natriuretic peptide (ANP) was measured in six cirrhotic patients with massive refractory ascites, under strict metabolic conditions, while they were receiving a 20-meq sodium diet, both before and at two-hour intervals for eight hours following peritoneovenous shunting (PVS). The mean preoperative level of ANP was 75 +/- 18 pg/ml, which was found to be significantly higher than the normal range for this laboratory (8 to 24 pg/ml) (p less than 0.05). This value was also significantly higher than the value of 21 +/- 5 pg/ml (p less than 0.05) obtained in six patients with cirrhosis but without ascites. Following shunt insertion, an immediate natriuresis and diuresis were observed in five of the six cirrhotic patients with refractory ascites. In these five, right atrial pressure and ANP rose immediately, followed by a rise in the level of urinary cyclic guanosine monophosphate. The sixth subject had a delayed rise in right atrial pressure, and correspondingly the rise in ANP, the diuresis, and natriuresis were delayed. The changes in ANP following PVS were positively correlated with changes in right atrial pressure (p less than 0.05), urinary cyclic guanosine monophosphate (p less than 0.05), urinary sodium excretion (p less than 0.05), and urine volume (p less than 0.01). These results suggest that ANP may be important in mediating the acute response to PVS.     

Treatment of malignant ascites in patients with advanced cancer: peritoneovenous shunt versus paracentesis

BACKGROUND: Malignant ascites in patients with advanced cancer is often difficult to treat and effective palliation is not achieved. METHODS: We performed peritoneovenous shunt (PVS) placement in patients with malignant ascites, who were admitted to our institution between January 2000 and March 2005. The outcome of PVS placement was compared with paracentesis as a treatment option during the same period. Comparisons included changes in abdominal girth, hematocrit (Hct), blood urea nitrogen (BUN) and creatinine (Cr) measurements before and after PVS placement. The number of procedures, changes in the postoperative performance score, the median survival, possibility of discharge, and complications were compared between the two groups. RESULTS: Twenty patients underwent PVS placement and 49 patients were subjected to paracentesis. After PVS, abdominal girth and Hct decreased significantly. BUN and Cr tended to decrease. The median number of procedures was less in the PVS group than in the paracentesis group (one vs two, respectively; P < 0.0001). The postoperative performance score showed a significant improvement following PVS placement (P = 0.0026). Median survival was significantly longer for patients undergoing PVS placement than for those undergoing paracentesis (42 days vs 18 days, respectively; P = 0.003). The rate of possible discharge was significantly higher for patients undergoing PVS placement (P = 0.0076). Severe complications were observed in one patient in the PVS group and in seven patients in the paracentesis group. CONCLUSIONS: PVS placement provides an effective treatment option for patients with refractory malignant ascites in advanced cancer, and yields a higher likelihood of discharge compared with conventional paracentesis.     

Right heart pseudotumor simulated by ascitic pseudocyst. An unusual complication of peritoneovenous shunting

Peritoneovenous shunting (PVS) for intractable ascites has an extensive clinical experience, with several well-described complications. We recently noted an unusual complication of PVS with a Denver shunt. A 37-year-old woman who had placement of a shunt for chylous ascites 18 months prior to presentation demonstrated on a large, mobile mass filling the right atrium which, during atrial systole, partially prolapsed into the right ventricle. At cardiac surgery, a 4 X 10 cm mass with attachment to the tip of the shunt was found. Intracardiac ascitic pseudocyst is a potentially lethal complication of PVS with the Denver shunt which should be considered with a high index of suspicion and evaluated with echocardiography.     

Denver peritoneovenous shunting for malignant or cirrhotic ascites. A prospective consecutive series

A Denver peritoneovenous (PV) shunt was inserted in 54 consecutive patients for relief of malignant (24 patients) or cirrhotic (30) refractory ascites. The median age of both groups was 58 years, and the most frequent diagnoses were gastrointestinal (15) or ovarian (7) cancers and alcoholic cirrhosis (25). Median survival time was 1.7 and 3.5 months (range, 0.1-15.5 and 0.1-50.5), and the 1-month mortality 42% and 27%, respectively. Postoperative 24-h urinary output increased by 2-31, and the 1-week weight reduction was 8 and 11 kg, respectively, compared with before shunting. Complete shunt failure was encountered early in two patients, due to catheter malposition and clotting. Four more patients experienced transient failure, for an early dysfunction rate of 11%. A shunt-related operative mortality of 6% was caused by pulmonary oedema (two patients) and sepsis (one patient). Shunt malfunction intervened in almost half (6 of 14) of the cancer patients surviving 1 month but was relieved in all but 1. In 3 of 22 cirrhotic 1-month survivors, the Denver shunt had to be removed owing to clotting or sepsis (2 patients) or revised because of blockage. Seven patients with cirrhosis are alive a median of 18 months (range, 2-51) after PV shunt surgery. Side effects were detected in 22 patients (41%): thromboembolism (9 patients), sepsis (7), initially bleeding oesophageal varices (3), DIC syndrome (2), postoperative hepatic coma (2), ascitic leakage (2), and pulmonary oedema (2). Patients with gastrointestinal cancers or severe cardiac disease did not benefit from the procedure. A history of hepatic encephalopathy or a serum bilirubin level above about 100 mumol/l was a bad prognostic sign. We could confirm the reported considerable morbidity and mortality after PV shunting, but also its efficiency in certain cases. Careful patient selection and follow-up study, timing of operation, and adherence to technical details are mandatory to improve the results.     

Dialytic Ultrafiltration by Hemofilter in Treatment of Patients with Refractory Ascites and Renal Insufficiency

Six cirrhotic patients with intractable ascites had coexisting renal insufficiency. Dialytic ultrafiltration of ascitic fluid by hemofilter was attempted in these patients for symptomatic relief. The hemofilter removes fluid and substances with a molecular weight less than 50,000 daltons and the concentrated ascitic fluid was reinfused into the peritoneal cavity after ultrafiltration. A transient increase in urine output (p less than 0.01), urinary sodium excretion (p less than 0.01), and endogenous creatinine clearance (p less than 0.02) was noted and the plasma creatinine levels had remained stable for more than 4 months after the procedure. Our study suggests that dialytic ultrafiltration of ascites by hemofilter is a safe method in the management of patients with refractory ascites and renal insufficiency.     

Peritoneovenous shunting for refractory ascites results in worsening of nephrotic syndrome

Peritoneovenous shunt (PVS) is accepted as a treatment for refractory ascites due to liver cirrhosis. Infection is a well‐known complication of shunting. However, the effects of PVS in terms of complications for renal disease are unclear. We encountered a case involving a 52‐year‐old man with alcoholic liver cirrhosis and complications of nephrotic syndrome that were worsened by PVS. He received PVS for refractory ascites due to alcoholic liver cirrhosis before coming to our hospital for evaluation for liver transplantation. Nephrotic syndrome was then identified due to cirrhosis‐related membranoproliferative glomerulonephritis (MPGN). Prednisolone was administrated at 60 mg/day for MPGN. On day 5, he showed grade IV hepatic encephalopathy (West Haven criteria). Tapering prednisolone and intestinal cleansing with lactulose treatment improved hepatic encephalopathy, but hyperammonemia persisted and the PVS was removed. After shunt removal, urinary protein levels decreased from 4–6 g/day to 0.3–0.5 g/day and ammonia levels decreased. PVS may increase the excretion of urinary protein and increase ammonia levels in patients with complications of glomerulonephritis.     

Pleurovenous shunt in treating refractory nonmalignant hepatic hydrothorax: a case report

We report a case of successful, long-term pleurovenous shunt (PVS) in treating refractory nonmalignant hepatic hydrothorax. An 82-year-old woman with liver cirrhosis, hypertension complicated with chronic renal failure while on hemodialysis, presented with progressive dyspnea in association with a recurrent right-sided pleural effusion, occurring secondary to transdiaphragmatic migration of ascites. The diagnosis was established by a demonstration of (99m)Tc-sulphur colloid sequential scintigraphic scan. Despite repetitive thoracenteses and traditional medical treatment, she suffered dyspnea without relief. Denver peritoneovenous shunt was inserted into the right-sided pleural cavity to drain effusion into the subclavian vein without short- and long-term complications. Manually pumping schedule of 10 min was performed twice daily to remove pleural fluid into the venous circulation for maintaining shunt patency. After 19 months of follow-up, the patient is doing well and PVS remains patent without significant pleural effusion. PVS opens a window of opportunity and offers an alternative procedure with minimal invasiveness for high-risk patients with refractory hepatic hydrothorax. It could be an alternative treatment to other conventional surgical interventions.     

腹水超滤浓缩回输腹腔治疗肝硬化顽固性腹水疗效评价

目的 评估腹水超滤浓缩回输腹腔术治疗肝炎肝硬化顽固性腹水患者临床疗效。方法75例肝硬化顽固性腹水患者分为治疗组（50例）和对照组（25例）,两组患者均采用保肝、利尿、对症、支持等常规治疗,疗程4周。对照组在常规治疗基础上,采用多次治疗性腹穿放液治疗;治疗组在常规治疗基础上,采用腹水超滤浓缩回输腹腔治疗,观察并比较两组治疗后体重、腹围、24h尿量和尿钠排出量、肝功能、肾功能、血电解质及不良反应。结果治疗4周后治疗组腹围、体重、24h尿量优于对照组（P〈0．01）;血清白蛋白、肾小球滤过率及24h尿钠量高于对照组（P〈0．01）,肌酐、胱抑素c水平低于对照组（P〈0．05。P〈0．01）;治疗组显效率（48．0％）和总有效率（80．0％）明显好于对照组（24．0％和52．0％）（P〈0．05）：两组均未出现严重不良反应。结论腹水超滤浓缩回输腹腔术治疗肝硬化顽固性腹水患者临床疗效优于多次治疗性腹穿放液。