Chronic hepatic encephalopathy due to spontaneous splenorenal shunt: Successful treatment by transhepatic shunt embolization

A spontaneous splenorenal shunt, leading to chronic hepatic encephalopathy, was treated by transhepatic occlusion with coils and Enbucrylate. There were no complications. Hepatic encephalopathy subsided.     

Post-TIPS hepatic encephalopathy treated by occlusion balloon-assisted retrograde embolization of a coexisting spontaneous splenorenal shunt

A 51-year-old man with posthepatitis cirrhosis underwent a transjugular intrahepatic portosystemic shunt (TIPS) for bleeding of recurrent esophageal varices. The patient had a coexisting, spontaneous, splenorenal shunt. He subsequently developed hepatic encephalopathy, presumably due to excessive portosystemic shunting. Since medical management resulted in no significant improvement, the splenorenal shunt was embolized from the jugular vein approach via renal vein access during temporary balloon occlusion. Within a few days, the patient's hepatic encephalopathy resolved. Twelve months later the patient showed no recurrence of encephalopathy and had maintained a patent TIPS.     

Treatment of hepatic encephalopathy by retrograde transcaval coil embolization of an ileal vein-to-right gonadal vein portosystemic shunt

A 43-year-old non-cirrhotic woman suffered from encephalopathy caused by an extrahepatic portosystemic shunt between the ileal vein and inferior vena cava via the right gonadal vein. Percutaneous transcatheter embolization with stainless steel coils was performed by the retrograde systemic venous approach. Encephalopathy improved dramatically.     

Refractory hepatic encephalopathy due to concomitant transjugular intrahepatic portosystemic shunt and spontaneous mesocaval shunt controlled by embolization of the competitive portosystemic shunt

Spontaneous mesocaval shunt (SMCS) is an uncommon cause of refractory encephalopathy after transjugular intrahepatic portosystemic shunt (TIPS) creation. We report a patient who presented with refractory hepatic encephalopathy (HE) post-TIPS creation for variceal bleeding in whom a SMCS was found. Percutaneous transhepatic occlusion of the SMCS reduced the portal vein flow diverted from the liver and provided sufficient liver perfusion to reverse the HE while maintaining satisfactory decompression of esophageal varices.     

Portosplenic blood flow separation in a patient with portosystemic encephalopathy and a spontaneous splenorenal shunt

A patient with portosystemic encephalopathy, hyperammonemia, and a spontaneous splenorenal shunt was admitted to the authors' institution after a failed attempt at transvenous retrograde shunt obliteration. As an alternative approach, the authors separated splenic and portal flows by embolizing only the proximal splenic vein while leaving the shunt intact. Thus, the splenic flow could escape into the systemic circulation and an extreme increase in portal pressure was avoided. The procedure could provide rapid decreases in blood ammonia levels and a fast resolution of symptoms, but repeated interventions were required.     

Value of splenic embolization in patients with hypersplenism

The authors describe the importance of embolization of the splenic artery by means of Gianturco coils in splenomegalic portal hypertension. They propose their first experience of six cases and the good results on the basis of clinical parameters, of bleeding of esophageal varices, of hematological values. They also show the influence of this method on hemodynamic, metabolic, and respiratory parameters, altered in cirrhotic patients.     

门静脉高压病人部分脾栓塞术对门静脉及其分支压力的影响

目的　研究门脉高压,脾功能亢进病人部分脾栓塞（ＰＳＥ） 前后门脉压力改变,以期得到ＰＳＥ对门脉压力改变的影响。方法　采用脾动脉插管及经皮经肝门脉置管在ＰＳＥ前后分别测量门脉主干,脾静脉及肠系膜上静脉压力,通过自身对照ｔ 检验进行统计学研究。结果　ＰＳＥ前门脉主干（ＰＶ）压力为（５１ ．４±１３．７）ｃｍ Ｈ２Ｏ,脾静脉（ＳＶ）为（５５ ．５±２３ ．２）ｃｍ Ｈ２Ｏ,肠系膜上静脉（ＳＭＶ）为（５１．８±１７ ．２）ｃｍ Ｈ２Ｏ,ＰＳＥ后ＰＶ 为（４２．４ ±８．７）ｃｍ Ｈ２Ｏ,ＳＶ 为（４２．３±１１ ．８）ｃｍ Ｈ２Ｏ,ＳＭＶ 为（４３ ．４ ±１３．１）ｃｍＨ２Ｏ,通过自身对照“ｔ”检验,ＰＶ,ＳＶ 为Ｐ＜ ０ ．０５ ,ＳＭＶ 为Ｐ＜ ０ ．００１ 。结论　ＰＳＥ前后门脉主干及其分支压力改变经检验差别有统计学意义。ＰＳＥ术后短期内门脉及其分支压力可明显降低     

Partial splenic embolization in patients with idiopathic portal hypertension

PURPOSE: To evaluate the effectiveness of partial splenic embolization (PSE) in patients with idiopathic portal hypertension (IPH) in reducing variceal bleeding episodes, splenomegaly and thrombocytopenia. MATERIALS AND METHODS: Six patients (2M, 4F, mean age 30.3 years) with IPH presenting with splenomegaly, thrombocytopenia and recurrent variceal bleeding were treated with PSE using gelatin sponge (four patients) or Contour particles (two patients) as embolization material. RESULTS: PSE was performed successfully in all cases; 3F coaxial microcatheters were necessary in two patients due to extreme splenic artery tortuosity. The average amount of devascularized parenchyma at CT 1 week after PSE was 71%. Splenomegaly and thrombocytopenia improved in all cases, with a mean platelet count increase of 120,000/mm(3) and an average 68% reduction of spleen volume at follow up. Variceal bleeding did not recur after PSE. Esophageal or gastroesophageal varices disappeared (one patient) or significantly reduced (five patients) at endoscopic controls. No significant complications were noted. The follow up was of at least 18 months in all patients; mean follow up was 28.2 months. CONCLUSION: In patients with IPH PSE can be effective in preventing variceal bleedings, in reducing spleen volume and in significantly increasing platelet count; therapeutic results were durable in our population.     

Congenital intrahepatic portosystemic shunt with variant inferior right hepatic vein

We present a case of congenital intrahepatic aneurysmal portosystemic shunt in which the right portal vein communicates with both a variant inferior right hepatic vein and the right hepatic vein. We also describe the importance and efficacy of three dimensional computed tomography reconstruction images in determining subtle, small shunt vessels.     

Percutaneous transhepatic treatment of a posttransplant portal vein thrombosis and a preexisting spontaneous splenorenal shunt

Percutaneous transhepatic treatment of portal vein thrombosis after liver transplantation in a patient with a preexisting high volume spontaneous splenorenal shunt is presented. Local thrombolysis with urokinase and balloon angioplasty of the main portal vein stenosis were performed followed by shunt embolization to restore hepatopetal portal blood flow.     

Concomitant hepatic encephalopathy and refractory ascites: successful treatment with staged embolization of two large portosystemic shunts and transjugular intrahepatic portosystemic shunt placement

A patient with cirrhosis, refractory ascites, and two large competitive portosystemic shunts presented with uncontrollable acute exacerbation of chronic hepatic encephalopathy (HE). A staged procedure was performed by first performing embolization of a large mesogonadal shunt to treat the HE. Three months later, a transjugular intrahepatic portosystemic shunt (TIPS) was created to address the ascites. A large paraumbilical vein shunt was embolized at TIPS placement to minimize the risk of recurrent HE. At 9-month follow-up, the ascites was well controlled with medical management with little or no HE.     

部分性脾栓塞治疗肝癌患者脾功能亢进的疗效观察

目的　评价联合应用肝动脉栓塞灌注化疗和部分性脾栓塞治疗肝癌患者脾功能亢进的临床价值。方法　收集原发性肝细胞癌合并门脉高压患者 110例 ,经导管动脉栓塞 (TACE)同时行部分性脾栓塞 ,分 1～ 3次达到控制目的。脾栓塞采用 35 5～ 5 0 0 μmPVA微粒 ,脾下极动脉超选部分性脾栓塞。采集每次脾栓塞术前、术后资料 ,包括症状、体征、外周血象、增强CT ,上消化道内镜所见 ,并进行统计学处理、分析。结果　共行部分性脾栓塞 172例次。栓塞范围 30 %～ 6 0 %。栓塞后有 134例次出现发热 ,持续 3～ 30d ,12 6例次出现腹痛 ,其中 2 7例次需用强效止痛药物。少量胸腔积液 6例次 ,保守治疗后消失。未出现脾脓肿等严重并发症。术后 2 4h外周血白细胞、血小板计数 (BPC)开始升高 (P <0 .0 5 ) ,末次栓塞后 3个月白细胞维持在正常值为 6 7例 ,BPC维持在正常值为 82例。术后食欲、体能以及胃底食管静脉曲张均有所改善。结论　部分性脾栓塞治疗肝癌合并脾功能亢进能有效改善血象 ,提高机体免疫力 ,提高生活质量。     

选择性门静脉栓塞术联合肝动脉化疗栓塞术治疗肝转移癌的对照研究

目的探讨选择性门静脉栓塞术(PVE)联合肝动脉化疗栓塞术(TACE)治疗肝转移癌的疗效和安全性。方法将49例无法或拒绝接受手术切除肝转移癌的患者分为对照组和治疗组。对照组(26例)单纯行TACE,治疗组(23例)在此基础上联合选择性门静脉栓塞术,观察比较2种疗法对患者术后肝功能、肝脏体积、不良反应、并发症及近期疗效和累积生存率的影响。结果①术后6个月治疗组有效率65.2%(15/23)高于对照组30.8%(8/26)(P=0.04);治疗组肿瘤最长径总和由术前(9.92±2.63)cm下降为术后(7.32±2.61)cm,对照组由术前(10.34±3.12)cm下降为术后(9.13±3.42)cm,治疗组优于对照组;治疗组和对照组中位生存时间分别为21个月及13个月,累积生存率比较P<0.05。②肝脏体积变化比较:对照组术后肝脏体积无明显变化;治疗组术前非栓塞叶体积为(481±251)cm3,术后2,4,8周分别为(523±250)cm3,(548±249)cm3,(552±249)cm3,分别比术前增加(10.1±7.6)%,(16.1±10.9)%,(17.2±11.5)%。③术后肝功能:两组患者术后血浆白蛋白水平变化均不明显,治疗组术后第1,3天,ALT、AST、TB等指标较术前明显升高,至术后第7天下降(P>0.05)。两组相比,术后第1天、第3天ALT、AST、TB治疗组高于对照组,第7、14天差异无统计学意义。结论选择性PVE联合TACE能够有效的控制和缩小肝转移癌,改善患者累积生存率,是治疗无法手术切除肝转移癌安全有效的选择,值得进一步研究应用。     

Partial splenic artery embolization in cirrhotic patients

Splenomegaly is a common sequela of cirrhosis, and is frequently associated with decreased hematologic indices including thrombocytopenia and leukopenia. Partial splenic artery embolization (PSE) has been demonstrated to effectively increase hematologic indices in cirrhotic patients with splenomegaly. This is particularly valuable amongst those cirrhotic patients who are not viable candidates for splenectomy. Although PSE was originally developed decades ago, it has recently received increased attention. Presently, PSE is being utilized to address a number of clinical concerns in the setting of cirrhosis, including: decreased hematologic indices, portal hypertension and its associated sequela, and splenic artery steal syndrome. Following PSE patients demonstrate significant increases in platelets and leukocytes. Though progressive decline of hematologic indices occur following PSE, they remain improved as compared to pre-procedural values over long-term follow-up. PSE, however, is not without risk and complications of the procedure may occur. The most common complication of PSE is post-embolization syndrome, which involves a constellation of symptoms including fever, pain, and nausea/vomiting. The rate of complications has been shown to increase as the percent of total splenic volume embolized increases. The purpose of this review is to explore the current literature in regards to PSE in cirrhotic patients and to highlight their techniques, and statistically summarize their results and associated complications.     

部分脾动脉栓塞术治疗脾功能亢进致血小板减少的疗效观察

目的观察部分脾动脉栓塞术治疗脾功能致血小板减少的临床疗效。方法选择2005年8月至2006年9月期间因脾功能亢进而导致血小板减少的60例患者行部分脾动脉栓塞术，观察并统计其血小板数的变化。结果所有患者术后血小板数较术前均显著上升。结论部分脾动脉栓塞术对治疗脾功能亢进致血小板减少有显著的疗效。     

脾修补术、部分切除术及动脉栓塞术治疗创伤性脾破裂的疗效以及对患者免疫功能的影响

目的探讨对比脾修补术、部分切除术及动脉栓塞术治疗创伤性脾破裂的疗效及对患者免疫功能的影响。方法回顾性分析2015年1月—2018年12月海南医学院第一附属医院普外科收治的160例创伤性脾破裂患者,男性84例,女性76例;年龄37~68岁,平均45.86岁。其中50例行脾修补术(修补组),55例行脾部分切除术(切除组),55例行脾动脉栓塞术(栓塞组)。对三组患者的手术情况、手术疗效及手术前后外周血T淋巴细胞变化进行对比、分析。结果栓塞组的手术时间为(116.42±34.37)min,显著低于另外两组的(224.36±42.58)min和(218.74±36.04)min;栓塞组的术后住院时间为(7.85±1.30)d,显著低于另外两组的(10.36±2.74)d和(11.09±3.14)d;栓塞组的术中输血量为(205.80±46.68)mL,显著少于另外两组的(576.32±51.74)mL和(560.68±49.92)mL(P<0.05)。三组的手术总有效率分别为94%、87%和95%,组间比较差异无统计学意义(P>0.05)。与术前相比,三组术后2周的CD3^+、CD4^+、CD4^+/CD8^+、IgG、IgA及IgM水平均明显降低,术后4周较术后2周有所提高。栓塞组术后4周的CD3^+、CD4^+、CD4^+/CD8^+、IgG、IgA及IgM水平分别为(60.95±3.77)%、(36.07±4.45)%、(1.21±0.14)%、(11.20±1.84)g/L、(1.59±0.36)g/L、(0.96±0.27)g/L,均与术前对应值接近,但均显著高于另外两组对应值(P<0.05);栓塞组术后2周CD3^+、CD4^+、CD4^+/CD8^+、IgG、IgA及IgM水平分别为(50.96±2.14)%、(32.20±3.17)%、(1.09±0.07)%、(9.05±1.66)g/L、(1.21±0.35)g/L、(0.82±0.23)g/L。栓塞组术后并发症总发生率为7%,显著低于修补组(24%)和切除组(20%),P<0.05。结论脾修补术、部分切除术和动脉栓塞术治疗创伤性脾破裂均有较好的效果,其中脾动脉栓塞术的操作更简单、创伤更小、并发症更少、免疫功能恢复更快,应用优势更显著。     

经颈静脉肝内门体分流术后肝性脑病研究进展

【摘要】 经颈静脉肝内门体分流术（TIPS）已在临床上大规模应用。TIPS治疗肝硬化门静脉高压所致并发症效果显著，但术后肝性脑病（HE）发生率高。该文就TIPS术后HE发生机制、分型和分级、危险因素及治疗作一综述。