肝硬化门静脉高压症患者Hassab术后门静脉血流动力学变化及意义

用彩色多普勒检测肝硬化门静脉（PV）高压症患者Hassab术后不同时期PV主干和门静脉左支（LPV）、右支（RPV）内径及最大血流速度、平均血流速度,评价术后不同时期Child-Pugh肝功能分级。结果与术前比较,Hassab术后12个月时PV主干内径、RPV内径较术前14 d时缩小（P〈0.05）,LPV变化不明显（P〉0.05）,PV主干和LPV最大血流速度、LPV平均血流速度减慢,血流量减少（P〈0.05）。RPV平均血流速度在术后6个月时较术前减慢（P〈0.05）。术后3~24个月Child-Pugh A级患者比例升高,与术前比较,P〈0.05。认为Hassab术后12个月,PV主干及RPV内径不同程度缩小,其血流速度、血流量均不同程度减慢、减少。术后24个月内肝功能改善明显。     

索非布韦联合利巴韦林治疗对丙型肝炎肝硬化患者肝功能及门静脉高压的影响

目的评估直接抗病毒药物索非布韦联合利巴韦林在慢性丙型肝炎肝硬化患者中改善肝功能和降低门静脉高压的临床安全性和有效性。方法前瞻性纳入50例慢性丙型肝炎肝硬化患者,将患者随机分为实验组和观察组各25例,实验组患者入组后即开始索非布韦400 mg 1次/d和利巴韦林1 000 mg 2次/d治疗、持续24周;观察组患者在接受12周的观察期后于第13周开始接受索非布韦和利巴韦林治疗、并持续至第24周。主要评价指标是治疗完成后12周随访时的持续病毒应答(SVR-12),次要评价指标包括治疗结束后随访12周时的肝静脉压力梯度(HVPG)、MELD和Child-Pugh评分的改善。结果观察组中有4例患者在前12周的观察期内退出本研究中,故以46例患者为统计分析对象。整体上,46例患者的SVR-12率为71.7%(33/46)。Child-Pugh A级患者的SVR-12率为77.8%(14/18),高于Child-Pugh B级患者的SVR-12率67.9%(19/28),但无统计学差异(P0.05);实验组患者的SVR-12率为76.0%(19/25)、观察组患者的SVR-12率为66.7%(14/21),但无统计学差异(P0.05)。46例患者在治疗结束后12周随访时的HVPG较基线水平降低(2.4±3.2) mmHg(P0.05)、MELD评分较基线水平降低(1.7±2.1)(P0.001)、Child-Pugh评分较基线水平降低(0.9±1.3)(P0.001)。治疗过程中未出现治疗相关严重不良反应的发生。结论直接抗病毒药物索非布韦和利巴韦林的联合应用促进慢性丙型肝炎肝硬化患者的SVR效应、并促进肝功能的改善和HVPG的降低。     

乙型肝炎病毒相关肝硬化的临床诊断、评估和抗病毒治疗的综合管理

正1背景慢性乙型肝炎病毒(hepatitis B virus,HBV)感染是肝硬化的重要原因。研究显示,有效抑制HBV复制可改善肝纤维化[1,2],延缓或阻止代偿期肝硬化向失代偿期的进展,减少失代偿期患者病情进一步恶化,减少门静脉高压及相关并发症发生[3-6],延长生存期[3,4]。因此,有效的抗病毒治疗对改善疾病临床结局具有重要意义[7],也是目前HBV相关     

Viatorr覆膜支架用于TIPS术治疗肝硬化门静脉高压症患者预后研究

目的 研究Viatorr覆膜支架用于经颈静脉肝内门体静脉分流术(TIPS)治疗肝硬化门静脉高压症患者的疗效和转归.方法 2018年1月～2020年1月我院收治的肝硬化并发门静脉高压症患者146例,采用随机数字表法将患者分为对照组73例和观察组73例,在接受TIPS术治疗时分别使用裸支架联合Fluency覆膜支架或Via...     

奥曲肽联合普萘洛尔治疗肝细胞癌并发门脉高压症患者门静脉血流动力学的变化

目的 观察奥曲肽联合普萘洛尔对原发性肝癌（PLC）并发门脉高压（PHT）患者相关静脉血流量和门静脉血流动力学指标的影响。方法 将纳入研究的84例PLC并发PHT患者随机分为观察组44例和对照组40例,给予观察组患者奥曲肽和普萘洛尔,给予对照组普萘洛尔治疗,3天后观察脾静脉、门静脉、肝静脉血流量和门静脉血管内径、平均血流速度（TAV）、血流量（BF）]的变化。结果 治疗后,观察组门静脉血流量为（712.55±83.76）ml/min,显著低于对照组【（826.53±106.92）ml/min,P<0.05】,脾静脉血流量为（273.45±43.17） ml/min,显著低于对照组【（332.31±53.93）ml/min,P<0.05】,肝静脉血流量为（1232.17±792.63）ml/min,与对照组【（1195.65±801.37）ml/min,P>0.05】比,无统计学差异;治疗后,观察组门静脉直径为（10.88±0.31）mm,显著小于对照组【（11.48±0.59）mm,P<0.05】,PVP为（2.36±0.64）kPa,显著低于对照组【（2.89±0.66）kPa,P<0.05】,TAV为（14.93±2.56）cm/s,显著快于对照组【（13.75±2.35）cm/s,P<0.05】。结论 奥曲肽和普萘洛尔联合应用能更好地控制PLC并发PHT患者的门静脉高压症。     

经颈静脉肝内门体静脉分流术治疗门脉高压症45例临床观察

经颈静脉肝内门体静脉分流术(TIPS)是一项治疗门静脉高压症的新技术,其是通过介入放射学的方法,在肝内建立一条连接门静脉与肝静脉的限制性分流通道,从而达到有效降低门静脉压力的目的.2002年7月～2006年12月,我们对45例肝硬化门脉高压症患者行TIPS治疗,疗效显著.现报告如下.     

应用RGT策略抗病毒获得SVR后复发的6例慢性丙型肝炎患者临床分析

聚乙二醇化干扰素（Peg IFN）联合利巴韦林（RBV）是目前CHC抗病毒治疗的标准方案[1],近年来,应答指导治疗（RGT）研究进展迅速,患者因此取得持续病毒学应答（SVR;治疗结束后随访24周,血清HCV RNA低于检测下限）的比例大幅提高。     

临床上有显著门静脉高压症的患者口服抗HCV药物治疗后的血流动力学变化及临床结果

正【据Journal of Hepatology 2020年5月报道】题:临床上有显著门静脉高压症的患者口服抗HCV药物治疗后的血流动力学变化及临床结果(作者Lens S等)在使用直接抗病毒药物治疗的丙型肝炎肝硬化患者中,有显著临床意义的门静脉高压症(CSPH,HVPG≥10 mm Hg)在持续病毒学应答(SVR) 24周后持续存在。这些患者仍有失代偿的风险。然而,长期配对的临床和血流动力学数据不适用于该人群。来自西班牙临床医院的Lens等纳入226例有HCV相关性肝硬化及CSPH且在抗病毒治疗后获得SVR的患者。     

抗病毒治疗对HBV DNA阳性乙型肝炎肝硬化门脉高压症患者术后临床转归的影响*

目的 探讨抗病毒治疗对血清HBV DNA阳性的门脉高压症患者术后临床转归的影响。方法 将89例HBV DNA阳性乙型肝炎肝硬化伴门静脉高压症患者随机分成治疗组48例,采用选择性断流联合恩替卡韦治疗和对照组41例,采用单纯手术治疗。常规检测肝功能、HBV DNA定量、Child-Pugh评分和肝纤维化指标。结果 在术后1 m和3 m时,治疗组患者血清HBV DNA水平分别为（5.79±1.78） lgcopies/L和（4.24±1.61） lgcopies/L,显著低于对照组[分别为（7.90±1.83） lgcopies/L和（6.46±1.43）lgcopies/L,P<0.05];治疗组患者血清ALT和总胆红素较对照组降低,白蛋白升高;治疗组1 a生存率为93.75%,3 a生存率为75%,对照组患者1 a生存率为87.92%,3 a生存率为68.30%,治疗组显著高于对照组（P＜0.05）。结论 抗病毒治疗可以促进HBV DNA阳性的门脉高压症患者术后肝功能恢复,改善患者预后。     

脾切除联合贲门周围血管离断术治疗肝硬化并发门静脉高压症患者血细胞和肝功能的变化

目的 观察脾切除联合贲门周围血管离断术治疗肝硬化并发门静脉高压症患者外周血血细胞和肝功能的变化。 方法 2014年3月~2017年2月我院收治的行脾切除联合贲门周围血管离断术的肝硬化并发门静脉高压症患者95例,观察了术后3个月和12个月血常规和肝功能的变化。 结果 患者术后12个月外周血RBC、WBC、Hb、PLT分别为（4.2±0.8）×1012/L、（8.9±3.5）×109/L、（115.4±24.7）g/L、（217.5±74.2）×109/L,较术前【（3.7±0.8）×1012 /L、（3.4±1.3）×109/L、（98.7±18.6）g/L、（42.6±14.3）×109/L】明显升高（P<0.05）;术后肝功能指标和Child-Pugh计分明显改善。 结论 肝硬化并发门静脉高压症患者行脾切除联合贲门周围血管离断术后,近期血细胞和肝功能得到显著改善。     

Predictive factors for long‐term survival in patients with clinically significant portal hypertension following resection of hepatocellular carcinoma

Background: Hepatic resection for hepatocellular carcinoma (HCC) is not currently recommended for patients with clinically significant portal hypertension (PHT); however, recent studies have shown similar post‐operative outcomes between patients with and without clinically significant PHT. Aim: To clarify the post‐operative prognostic relevance of clinically significant PHT in Child–Pugh A cirrhotic patients. Methods: A total of 100 Child–Pugh A cirrhotic patients who underwent curative resection of HCC were eligible for this analysis. Patients were divided into two groups: PHT group (n=47) and non‐PHT group (n=53). Results: Clinicopathological variables showed no significant differences except for prothrombine time. Liver‐related complications were significantly higher in the PHT group (P=0.015), and the 5‐year overall survival rate was significantly higher in the non‐PHT group (78.7 vs. 37.9%, P<0.001). The proportion of patients who died because of complications of cirrhosis was significantly higher in the PHT group (P=0.001). Multivariate analysis indicated that the presence of clinically significant PHT was the most powerful adverse prognostic factor for overall survival. Multivariate analysis of the 47 patients with clinically significant PHT indicated that gross vascular invasion and non‐single nodular type were poor prognostic factors. The 5‐year survival rate of patients with single nodular type and without gross vascular invasion (n=17) was 78.4%. Conclusions: In Child–Pugh A cirrhotic patients, the presence of clinically significant PHT was significantly associated with post‐operative hepatic decompensation and poor prognosis after resection of HCC. However, in patients with clinically significant PHT, those with single nodular tumours lacking gross vascular invasion may be good surgical candidates.     

Noninvasive prediction of clinically significant portal hypertension and esophageal varices in patients with compensated liver cirrhosis

OBJECTIVES: We aimed to develop a model based on noninvasive variables for the prediction of clinically significant portal hypertension (CSPH) and of esophageal varices (EV) in patients with compensated liver disease.
METHODS: Sixty patients with compensated liver cirrhosis diagnosed by histology were included in the training set. All patients had physical examination, laboratory tests, abdominal color-Doppler ultrasound, upper digestive tract endoscopy, and measurement of hepatic venous pressure gradient. Predictive models for the presence of CSPH and of EV were calculated. The models were validated in an independent series of 74 patients with compensated liver disease.
RESULTS: Clinical and laboratory variables were selected in the final models, while ultrasonography did not add statistical power for the prediction of CSPH and EV. The model for prediction of CSPH included albumin, INR, and ALT. The best cutoff had 93% sensitivity and 61% specificity in the training set, and correctly classified 77% of patients in the validation set. Spider angiomas, ALT, and albumin predicted EV. The best cutoff of the model in the training set had a sensitivity of 93% and a specificity of 37% and correctly classified 72% of cases in the validation set.
CONCLUSIONS: Noninvasive prediction of EV in well-compensated cirrhotic patients is not accurate. However, a model obtained by combining simple laboratory variables has a high sensitivity to predict CSPH in this population and may be useful to select the subset of patients requiring screening endoscopy. By this method, endoscopic screening could be obviated in about 40% of patients.     

Power of outcome measurements to detect clinically significant changes in pulmonary rehabilitation of patients with COPD

STUDY OBJECTIVES: Several validated instruments are used to measure outcomes, such as exercise performance, dyspnea, and health-related quality of life after pulmonary rehabilitation (PR) in patients with COPD. However, no study has simultaneously compared the responsiveness of the most frequently used outcome measurements after PR. We designed this study to investigate the capacity of several of the most frequently used outcome measurements to detect changes after PR in a population of patients with severe COPD who qualified for lung volume reduction surgery. DESIGN, PATIENTS, AND INTERVENTIONS: We evaluated 37 patients with severe COPD (FEV(1) < 40%) before and after 6 to 8 weeks of outpatient PR. The following frequently used tools were evaluated: the 6-min walk distance (6MWD); functional dyspnea with the Medical Research Council (MRC) scale; baseline and transitional dyspnea index (BDI/TDI); resting and 6MWD visual analog scale (VAS); quality of life with a generic tool (the Short Form-36 [SF-36]); and two disease-specific tools, the Chronic Respiratory Disease Questionnaire (CRQ) and the St. George's Respiratory Questionnaire (SGRQ). RESULTS: After PR, mean +/- SD 6MWD increased in 33 of 37 patients (89%), from 285 +/- 97 to 343 +/- 92 m (p = 0.009). Improvements were seen also in the MRC scale in 23 of 37 patients (62%; from 2.27 +/- 0.8 to 1.86 +/- 0.6; p = 0.01); in CRQ dyspnea in 25 of 37 patients (67%; from 3.25 +/- 0.9 to 3.90 +/- 1.4; p = 0.02); in CRQ mastery in 22 of 37 patients (60%; from 4.37 +/- 1.4 to 5.14 +/- 1.3; p = 0.01); and in BDI/TDI functional in 24 of 37 patients (64%; from 1.4 +/- 0.8 to 0.7 +/- 1.1; p = 0.002). There were smaller improvements in the SGRQ in 18 of 37 patients (48%) and in the SF-36 in 19 of 37 patients (51%), but they were not statistically significant. There were good correlations between the dyspnea components of all the tools. The 6MWD change did not correlate with the changes in the other outcomes. Clinically significant changes in the values for those outcome tools were detected in > 50% of patients for the BDI/TDI, 29% of patients for the MRC scale, in 37% of patients for the 6MWD, in 48% of patients for the VAS at peak exercise, in > 50% of patients for the CRQ, and in 40% of patients for the SGRQ. CONCLUSIONS: We conclude that the VAS peak exercise, BDI/TDI, and CRQ adequately reflect the beneficial effects of PR. The 6MWD evaluates a unique domain not related to quality of life. Due to their simplicity and sensitivity, VAS at peak exercise, 6MWD, and CRQ may be the best practical tools to evaluate responsiveness to PR.     

Impact of HCV eradication with direct-acting antiviral agents on serum gamma globulin levels in HCV and HCV/HIV coinfected patients

Backgroundchronic viral infections by both HCV and HIV may lead to polyclonal activation of B cells resulting in hypergammaglobulinemia. This study retrospectively analyzed the effect of HCV eradication with interferon-free direct-acting antiviral agents (DAAs) on the gamma globulin levels in HCV-infected patients with or without HIV coinfection to identify factors potentially associated with gamma globulins decrease.MethodsThe charts of patients treated with DAAs for HCV chronic infection between January 2015-June 2019 were retrospectively reviewed. Gamma globulin levels before treatment and 12 weeks after the end of anti-HCV therapy were evaluated along with liver tests, liver fibrosis stage by elastography, SVR achievement, HIV-coinfection. Multivariate analyses were carried out to assess the factors and the potential confounders related to the changes in gamma globulin levels.ResultsA significant decrease of gamma globulin concentration was found in both cirrhotic and non-cirrhotic HCV-infected patients after treatment (from mean ± SD of 1.5 ± 0.44 g/dL to 1.31 ± 0.37 g/dL; p = 0.0001). Adjusted linear regression analyses of serum gamma globulin changes from baseline to SVR12 showed a positive significant association with pre-treatment gamma-globulin levels (β-coefficient −0.23; p = 0.0001), Metavir fibrosis score (β-coefficient -0.74; p = 0.008), ALT values and baseline HCV-RNA levels > 800,000. No difference was found between HIV-infected and HIV-uninfected patients.ConclusionsOur study confirms previous preliminary observation of the decrease of serum gamma globulins after HCV eradication either achieved with interferon-based therapy or with DAAs, suggesting a leading role of the virus on the activation of B cell compartment and gamma globulins production.     

Systemic hemodynamic changes in mansonic schistosomiasis with portal hypertension treated by azygoportal disconnection and splenectomy

OBJECTIVE: The aim of this study was to assess systemic hemodynamic changes in patients with Manson's schistosomiasis and portal hypertension during azygoportal disconnection and splenectomy. METHODS: Sixteen patients with portal hypertension secondary to hepatosplenic schistosomiasis with indication for surgery were studied prospectively. All underwent invasive hemodynamic monitoring with pulmonary artery catheter. The first systemic hemodynamic assessment was performed preoperatively. In the intraoperative period new hemodynamic data were collected as follows: a) after laparotomy; b) 15-30 min after splenic artery ligature; c) 15-30 min after splenectomy; and d) after ligation of the collateral circulation. RESULTS: The results indicated preoperatively that the patients presented with an increased cardiac index (4.40 +/- 0.94 L/min/m2) together with a reduction in the systemic vascular resistance index (1692.25 +/- 434.91 dyne.s/cm5.m2). The stroke index (53.74 +/- 10.40 ml/beat/m2) and both left (5.71 +/- 1.50 kg.m/m2) and right heart work indexes (1.12 +/- 0.74 kg.m/m2) were also elevated. The mean pulmonary artery pressure was increased (17.81 +/- 9.00 mm Hg) and the pulmonary vascular resistance index decreased (164.31 +/- 138.69 dyne.s/cm5.m2). From the moment that the splenic artery was ligated until the end of the procedure, the cardiac index (3.45 +/- 0.90 L/min/m2) was reduced and the systemic vascular resistance index (2059.50 +/- 590.05 dyne.s/cm5.m5) increased. The systolic index (44.25 +/- 11.01 ml/beat/m2) and the left ventricle work index (4.33 +/- 1.29 kg.m/m2) also reduced. The mean pulmonary artery pressure (19.18 +/- 9.21 mm Hg) and the right ventricle work index (0.94 +/- 0.62 mm Hg) remained elevated after the surgical procedure. CONCLUSIONS: The data allowed us to conclude that hepatosplenic schistosomiasis induces a hyperdynamic circulatory state that was corrected after splenectomy and azygoportal disconnection, remaining a mild pulmonary hypertension. Therefore, these changes are correlated with the portosystemic collateral circulation, especially as a consequence of splanchnic hyperflow.     

Endoscopic therapy in patients with Barrett's esophagus and portal hypertension

BACKGROUND: Endoscopic mucosal resection has been used to stage and treat early neoplasia in Barrett's esophagus. The ability to do this in the setting of portal hypertension has not been reported. OBJECTIVE: Our purpose was to describe the feasibility and efficacy of endoscopic mucosal resection in patients with portal hypertension and Barrett's esophagus. DESIGN: Retrospective case series. SETTING: Two tertiary referral centers. PATIENTS: Patients with Barrett's esophagus and high-grade dysplasia or adenocarcinoma in the setting of portal hypertension. INTERVENTION: Endoscopic mucosal resection of endoscopically visible lesions. MAIN OUTCOME MEASUREMENTS: Complete resection of neoplastic lesion, lack of variceal bleeding. RESULTS: Four patients were treated with endoscopic mucosal resection a total of 5 times. Endoscopic mucosal resection was successfully performed without significant GI bleeding. LIMITATIONS: This preliminary case series describes feasibility of the procedure. Whether this can be generalized remains to be determined, although it may be an option in poor surgical candidates. CONCLUSIONS: Endoscopic mucosal resection appears to be relatively safe in selected patients with portal hypertension and Barrett's esophagus. Further studies are needed to confirm these findings.