肝硬化患者自发性门体分流发生率及预后分析

目的肝硬化患者自发性门体分流发生率及治疗后预后情况分析。方法选择2017年6月—2018年11月于我院就诊的肝硬化合并门静脉高压患者220例,均采用TIPS手术降门脉高压,同时对术中发现自发性门体分流患者采用弹簧钢圈、血管硬化剂或Amplatzer封堵器进行封堵。统计所有患者中自发性门体分流发生率,对所有患者进行为期1年术后随访,记录患者死亡情况、术后并发症发生情况。结果 220例肝硬化门静脉高压患者中有85例38.64%合并自发性门体分流。合并自发性门体分流患者术后1年内肝性脑病累积发生率为32.41%、腹水为36.47%、上消化道出血为23.53%;支架畅通率在术后1年内降至78.82%。合并与未合并自发性分流患者术后1年内死亡率比较无明显差异(P0.05)。合并自发性门体分流患者术后1年内肝性脑病累积发生率32.41%与未合并自发性门体分流患者21.48%比较无显著差异(P0.05)。有肝性脑病病史是TIPS手术后1年内发生肝性脑病的独立危险因素(P0.05)。结论本研究中肝硬化门静脉高压患者自发性门体分流发生率为38.64%,在经TIPS联合封堵治疗后可达到封堵目的并有效降低患者门静脉高压,术后1年内肝性脑病累积发生率与患者术前有肝性脑病病史有关。     

肝硬化门静脉高压并发上消化道出血的3种手术方式比较分析

目的比较经颈静脉肝内门体分流术(TIPS)、经皮经肝食管胃底静脉曲张栓塞术(PTVE)及TIPS联合胃冠状静脉栓塞术(GCVE)在肝硬化晚期门静脉高压患者并发上消化道出血治疗中的效果及优劣性。方法回顾性分析2012年1月-2014年10月于铜川矿务局中心医院行手术治疗的肝硬化晚期门静脉高压并发上消化道出血患者167例,根据手术方法不同分为TIPS组(n=56)、PTVE组(n=53)及TIPS联合GCVE组(n=58)。比较3组患者治疗的手术时间、术后恢复时间、住院费用,术后消化道曲张改善程度、再出血发生率、肝性脑病发生率、腹水消除率,门静脉相关指标(门静脉内径、门静脉流速、门静脉压力)及肝功能指标(ALT、AST、TBil、白蛋白)的不同。计量资料多组间比较采用方差分析,进一步两两比较采用SNK-q检验;计数资料组间比较采用χ2检验。结果 3组的手术时间、住院费用、术后再出血发生率及术后肝性脑病发生率比较,差异均有统计学意义(F值分别为13.85、12.53,P值均0.05;χ2值分别为7.132、6.368,P值均0.05)。其中,TIPS组与PTVE组的住院费用比较,差异有统计学意义(q=2.84,P0.05);TIPS组与TIPS联合GCVE组的手术时间、住院费用、术后再出血发生率及术后肝性脑病发生率比较,差异均有统计学意义(q值分别为3.99、2.58,P值均0.05;χ2分别为7.396、6.183,P值均0.05);PTVE组与TIPS联合GCVE组的手术时间、住院费用、术后再出血发生率及术后肝性脑病发生率比较,差异均有统计学意义(q值分别为4.53、3.99,P值均0.05;χ2分别为7.534、5.461,P值均0.05)。结论 TIPS联合GCVE虽然手术时间较TIPS和PTVE长、住院费用高,但术后再出血及术后肝性脑病发生率显著降低。     

TIPS治疗对肝硬化门脉高压症患者血清MMP-2、MMP-9和VEGF水平的影响

目的探讨经颈静脉肝内门体静脉分流术(TIPS)治疗对肝硬化门脉高压症患者血清基质金属蛋白酶2(MMP-2)、MMP-9和血管内皮生长因子(VEGF)水平的影响及意义。方法将2016年1月—2017年5月在青海仁济医院普外科接受TIPS治疗的60例肝硬化门脉高压患者作为研究对象,评估术后疗效并记录术后并发症,观察术后肝功能指标[总胆红素(TBil)、ALT、AST、γ-谷氨酰转肽酶(γ-GT)]变化,血流动力学指标[门静脉直径(PVD),门静脉血流量(PVF),门静脉流速(PVV),脾静脉直径(SVD)、脾静脉血流量(SVF)和脾静脉血流速度(SVV)]变化,血清MMP-2、MMP-9和VEGF水平。结果 59例患者TIPS手术获得成功,手术成功率98.33%(59/60),手术总有效率93.33%(56/60);术后门静脉压力(18.91±4.33)cmH2O较术前[(32.54±6.17)cmH2O]明显降低(P0.05);术后1周患者TBil、ALT、AST、γ-GT水平均较术前明显升高(P0.05);术后3个月患者TBil、ALT、AST、γ-GT水平较术后1周明显降低(P0.05),与术前比较差异无统计学意义(P0.05);术后3个月患者PVD、PVF、SVD、SVF较术前明显降低(P0.05),PVV和SVV较术前明显升高(P0.05);术后3个月患者血清MMP-2、MMP-9和VEGF水平较术前明显下降(P0.05);术后1年支架狭窄发生率21.67%(13/60),肝性脑病发生率18.33%(11/60),消化道再出血发生率15.00%(9/60)。结论 TIPS治疗能够降低肝硬化门脉高压患者血清MMP-2、MMP-9和VEGF水平,可能对肝内及门体侧支循环血管生成起抑制作用。     

经颈静脉肝内门体分流术治疗原发性胆汁性胆管炎伴门静脉高压的效果评估

目的 旨在评估经颈静脉肝内门体分流术(TIPS)治疗原发性胆汁性胆管炎合并门静脉高压的长期疗效。方法 回顾性纳入2015年1月1日—2021年8月30日南京大学医学院附属鼓楼医院收治的接受TIPS治疗的102例患者,并分为原发性胆汁性胆管炎(PBC)组(n=41)及病毒性肝炎肝硬化组(n=81)。收集患者入院初的血常规、肝肾功能、凝血功能、门静脉血栓、肝性脑病、接受TIPS治疗的病因,术前的门静脉压力及手术使用的支架情况,同时计算Child-Pugh评分。随访资料收集术后上消化道再出血、支架失功、肝性脑病及生存预后相关资料,并进行分析。符合正态分布的计量资料2组间比较采用独立样本t检验;偏态分布的计量资料2组间比较采用Mann-Whitney U检验。计数资料2组间比较采用χ²检验。采用Kaplan-Meier法进行生存分析,采用Log-rank检验比较生存差异。结果 PBC组和病毒性肝炎肝硬化组患者门静脉压力较术前降低的中位百分比分别为33.00%和35.00%,2组比较差异无统计学意义(P>0.05)。随访结束时,PBC组和病毒性肝炎肝硬化组在支架失功率...     

TIPS治疗门脉高压及其并发的消化道出血2例

目的观察经颈静脉肝内门体分流术(TIPS)治疗肝硬变门脉高压及消化道出血的临床疗效.方法采用TIPS治疗肝硬变门脉高压观察其近期疗效、并发症.结果2例患者门静脉建立有效分流,成功率100%.门静脉压由5.4kPa及5.2kPa分别降至3.2kPa和2.8kPa,分流后食管静脉曲张1例消失,术后腹水1例消失、1例减少,术后2例患者出血均停止,术后1例患者并发肾功能衰竭,最后死亡.结论TIPS可迅速降低门静脉压力,近期疗效满意,中期疗效欠佳,术后可出现腹水再现、肾功能衰竭、支架狭窄闭塞、肝性脑病等.     

肝硬化门静脉高压患者行经颈静脉肝内门体分流术术中置入Viatorr支架分流门静脉左、右支血流对疗效的影响

目的探讨在经颈静脉肝内门体分流术(TIPS)术中置入Viatorr支架分流门静脉左支或右支血流对肝硬化门静脉高压患者疗效的影响。方法回顾性分析中国人民解放军西部战区总医院2016年3月-2019年12月接受TIPS治疗的肝硬化门静脉高压症120例患者的临床资料,根据术中造影判断穿刺门静脉靶点位置,将患者分为门静脉左支分流组(n=52)和右支分流组(n=68),分析两组患者术后复发出血、支架功能障碍、肝性脑病发生及生存状况。计量资料2组间比较采用t检验。计数资料2组间比较采用χ2检验。Kaplan-Meier曲线分析再出血率、支架通畅率、肝性脑病发生率及生存率。结果 120例患者手术成功率100%,近期止血率100%。门静脉压力术后较术前明显降低[(9.98±2.84) mm Hg vs (24.72±5.11) mm Hg,t=37.76,P 0.01]。累计再出血率术后12、24个月分别为3.2%、11.0%;肝性脑病累计发生率术后3、6、12、24个月分别为10.8%、13.6%、21.2%、24.5%;随访24个月累计29例肝性恼病患者中,Ⅰ+Ⅱ级23例,Ⅲ级6例;支架功能障碍累计发生率术后12、24个月分别为7.1%、21.4%。累计生存率术后12、24个月分别为92.0%、86.5%。门静脉左支分流组与右支分流组比较,患者术后支架通畅率、再出血率、肝性脑病发生率、生存率比较差异均无统计学意义(P值均 0.05)。结论 TIPS是治疗肝硬化门静脉高压安全、有效的方法;术中置入Viatorr支架,无论建立门静脉左支或右支分流,均不会影响患者的临床疗效。     

43例采用Viatorr支架行经颈静脉肝内门体分流术的临床研究

目的:探讨采用Viatorr支架行经颈静脉肝内门体静脉分流术（TIPS）治疗肝硬化门静脉高压的临床疗效和安全性。方法:2016年3月至2018年8月,43例肝硬化门静脉高压患者在TIPS术中置入Viatorr支架,定期随访血清学指标、彩超、胃镜以及再出血、腹水和肝性脑病情况,门静脉压力、肝肾功能、凝血指标比较采用配对 ...     

经颈静脉肝内门腔静脉分流术治疗肝癌合并门静脉高压的临床研究

目的 探讨经颈静脉肝内门腔静脉分流术(TIPS)治疗肝癌合并门静脉高压的有效性、安全性和临床价值.方法 收集肝癌合并门静脉高压患者95例,其中63例行TIPS治疗(TIPS组),观察术后情况并随访生存期资料,其余32例(对照组)行内科支持治疗,随访生存期资料.评估TIPS组术后情况、术后肝性脑病、再出血、死亡原因等.行Kaplan-Meier生存分析比较两组中位生存时间,分析Child-Pugh分级及终末期肝病评估模式(MELD)评分与术后生存时间的关系.结果 TIPS组术后门静脉压力梯度平均降低13.6 cmH2O(1 cmH2O-0.098 kPa),术后6个月肝性脑病和再出血的累积发生率分别为20.6%和26.3%,截至随访结束死亡56例,其中最终死于门静脉高压破裂出血者12例.TIPS组中位生存期较对照组延长.TIPS组中MELD评分≤13分者中位生存时间大于评分>13分者(x2=4.71,P=0.03),Child-Pugh分级A到C级中位生存时间依次缩短(x2=15.6,P=0.00).结论 TIPS是治疗肝癌合并门静脉高压及其并发症安全有效的方法 ,应根据术前肝功能状况选择手术患者.     

伴自发性门体分流道显性肝性脑病的血管内治疗

目的初步评估伴自发性门体分流道(SPSS)的肝性脑病(HE)患者行分流道相关介入治疗的安全性、有效性。方法收集2017年1月至2021年3月因HE行SPSS介入治疗的6例患者病例资料, 评估其疗效, 术后并发症等情况。结果 6例患者均存在SPSS, 4例患者基础疾病为乙型肝炎肝硬化, 1例为酒精性肝硬化, 1例为肝动脉-门静脉瘘所致门静脉高压。肝功能评分为Child-Pugh C级3例, B级3例, SPSS类型为:胃肾分流2例;门静脉-胸壁静脉-奇静脉分流2例;门静脉-脐静脉-髂静脉分流1例;门静脉-脾静脉-下腔静脉分流1例。其中2例为既往曾经行经颈静脉肝内门体分流术(TIPS)治疗, TIPS术前存在其他SPSS。5例(5/6)成功行分流道栓塞, 1例(1/6)行支架植入限流(门静脉-脐静脉-髂静脉), 技术成功率100%, 住院期间及随访3个月均未再发HE, 1例术后1年再发HE予以对症治疗, 1例术后1年后发生消化道出血。结论 SPSS栓塞或者限流对改善HE患者症状有效且安全。     

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。     

Transjugular intrahepatic portosystemic shunt in cirrhosis: An exhaustive critical update

More than five decades after it was originally conceptualized as rescue therapy for patients with intractable variceal bleeding, the transjugular intrahepatic portosystemic shunt(TIPS) procedure continues to remain a focus of intense clinical and biomedical research. By the impressive reduction in portal pressure achieved by this intervention, coupled with its minimally invasive nature, TIPS has gained increasing acceptance in the treatment of complications of portal hypertension. The early years of TIPS were plagued by poor long-term patency of the stents and increased incidence of hepatic encephalopathy. Moreover, the diversion of portal flow after placement of TIPS often resulted in derangement of hepatic functions, which was occasionally severe. While the incidence of shunt dysfunction has markedly reduced with the advent of covered stents, hepatic encephalopathy and instances of early liver failure continue to remain a significant issue after TIPS. It has emerged over the years that careful selection of patients and diligent post-procedural care is of paramount importance to optimize the outcome after TIPS. The past twenty years have seen multiple studies redefining the role of TIPS in the management of variceal bleeding and refractory ascites while exploring its application in other complications of cirrhosis like hepatic hydrothorax, portal hypertensive gastropathy, ectopic varices, hepatorenal and hepatopulmonary syndromes, non-tumoral portal vein thrombosis and chylous ascites. It has also been utilized to good effect before extrahepatic abdominal surgery to reduce perioperative morbidity and mortality. The current article aims to review the updated literature on the status of TIPS in the management of patients with liver cirrhosis.     

介入性门腔分流术治疗门脉高压症所致曲张静脉出血及腹水疗效观察

目的 评价介入性门腔分流术治疗门脉高压症所致曲张静脉出血及腹水的疗效。方法 回顾性分析2004年2月—2010年1月我院55例良性门脉高压症行介入性门腔分流术患者的临床资料,观察分流道近期和远期的通畅情况,并分析生存时间和并发症。结果 手术成功率为100%,患者门静脉压力梯度(portal pressure gradient,PPG)均达到要求,即PPG≤1.60kPa或PPG降低2.00kPa。术后1～5年生存率分别为70.4%、60.8%、60.8%、60.8%、60.8%;分流道再狭窄率分别为7.3%、13.1%、24.0%、24.0%、24.0%;消化道曲张静脉出血复发率分别为9.8%、19.3%、26.0%、26.0%、26.0%;肝性脑病发生率分别为14.8%、23.9%、35.8%、57.2%、57.2%。结论 介入性门腔分流术治疗门脉高压症所致曲张静脉出血及腹水疗效可靠。如应用覆膜支架,门腔分流道通畅率较高。肝性脑病及复发性出血等并发症的发生率较低。     

The role of transjugular intrahepatic portosystemic shunt (TIPS) in the management of portal hypertension

Transjugular intrahepatic portosystemic shunt (TIPS) is an interventional radiology technique that has shown a 90% success rate to decompress the portal circulation. As a non-surgical intervention, without requirement for anesthesia and very low procedure-related mortality, TIPS is applicable to severe cirrhotic patients, who are otherwise untreatable, for example, nonsurgical candidates. TIPS constitutes the most frequently employed tool to achieve portosystemic shunting. TIPS acts by lowering portal pressure, which is the main underlying pathophysiologic determinant of the major complications of cirrhosis. Regarding esophagogastric variceal bleeding, TIPS has excellent hemostatic effect (95%) with low rebleeding rate (<20%). TIPS is an accepted rescue therapy for first line treatment failures in 2 settings (1) acute variceal bleeding and (2) secondary prophylaxis. In addition, TIPS offers 70% to 90% hemostasis to patients presenting with recurrent active variceal bleeding. TIPS is more effective than standard therapy for patients with hepatic venous pressure gradient >20mm Hg. TIPS is particularly useful to treat bleeding from varices inaccessible to endoscopy. TIPS should not be applied for primary prophylaxis of variceal bleeding. Portosystemic encephalopathy and stent dysfunction are TIPS major drawbacks. The weakness of the TIPS procedure is the frequent need for endovascular reintervention to ensure stent patency. The circulatory effects of TIPS are an attractive approach for the treatment of refractory ascites and hepatorenal syndrome, yet TIPS is not considered first line therapy for refractory ascites owing to unacceptable incidence of portosystemic encephalopathy. Pre-TIPS evaluation taking into account predictors of outcome is mandatory. The improved results achieved with covered-stents might expand the currently accepted recommendations for TIPS use.     

Differences in long-term survival after transjugular intrahepatic portosystemic shunt for refractory ascites and variceal bleed

OBJECTIVE: To compare the survival after transjugular intrahepatic portosystemic shunt (TIPS) for refractory ascites and variceal bleed, and to identify the factors predictive of survival. METHODS: Single tertiary center, retrospective-prospective study. Chart review was performed on all patients who underwent TIPS between 1993 and 2000 and prospective follow-up to determine survival. Pre- and post-TIPS clinical parameters were compared and Kaplan-Meier analysis was applied to compare the survival of both groups. Cox regression was used to identify predictors of survival after TIPS. RESULTS: A total of 163 patients were included, 62 with refractory ascites and 101 with variceal bleed. Both groups had similar age (48.2 vs 48.9 year; P = 0.65) and consisted of predominantly Caucasians (51%) and Mexican-Americans (39%). More than 75% had chronic hepatitis C, alcoholic liver disease or both. Overall, the median survival was significantly better for variceal bleed (2 years) compared with refractory ascites (6 months) (P < 0.001). This survival advantage persisted in patients with Mayo risk score greater than 1.17. Transjugular intrahepatic portosystemic shunt improved severe ascites in 45% of patients (P = 0.03). Mayo risk score was highly predictive of survival after TIPS with a hazard ratio of 2.3, followed by Child-Pugh score, creatinine, albumin and ethnicity, with better survival among Mexican-Americans. Shunt dysfunction (31%) and hepatic encephalopathy (27%) were the most common complications of TIPS. CONCLUSIONS: Patients who received TIPS for variceal bleed had significantly longer survival compared with those for refractory ascites. Mexican-Americans had an improved long-term survival compared with Caucasians. The reason for this ethnic difference in survival is unclear and warrants further prospective evaluation.     

肝硬化食管胃底静脉曲张破裂出血的急诊TIPS术可行性

目的探讨经颈静脉肝内门体分流术(transjugular intrahepatic portosystemic shunt,TIPS)用于急性肝硬化食管胃静脉曲张破裂出血的可行性。方法选择2011年9月至2013年9月收治的28例急性肝硬化食管胃静脉曲张破裂出血患者,均实施急诊TIPS术。结果 28例患者均1次操作成功接受TIPS术,术后24 h的止血率为100.0%。患者的平均门静脉压力术后较术前显著下降,分别为(27.01±5.32)和(38.23±7.41)cmH2O,门体循环压力差显著减小,分别为(18.76±4.70)和(30.45±7.69)cmH2O,经比较差异均有统计学意义(t=9.56,8.74,均P0.05)。术后,患者肝功能各项指标及凝血酶原时间较之术前均未出现显著改变,经比较差异均无统计学意义,(均P0.05)。术后随访3个月,所有患者支架均通畅,1例分流道为门静脉左支患者出现狭窄闭塞。1例患者出现肝性脑病,1例患者出现肝功能衰竭,经治疗无效死亡。结论急诊TIPS术用于急性肝硬化食管胃静脉曲张破裂出血可以获得良好的效果,安全性高。     

Combined transjugular intrahepatic portosystemic shunt and other interventions for hepatocellular carcinoma with portal hypertension

AIM: To evaluate combination transjugular intrahepatic portosystemic shunt(TIPS) and other interventions for hepatocellular carcinoma(HCC) and portal hypertension.METHODS: Two hundred and sixty-one patients with HCC and portal hypertension underwent TIPS combined with other interventional treatments(transarterial chemoembolization/transarterial embolization,radiofrequency ablation,hepatic arterio-portal fistulas embolization,and splenic artery embolization) from January 1997 to January 2010 at Beijing Shijitan Hospital. Two hundred and nine patients(121 male and 88 female,aged 25-69 years,mean 48.3 ± 12.5 years) with complete clinical data were recruited. We evaluated the safety of the procedure(procedurerelated death and serious complications),change of portal vein pressure before and after TIPS,symptom relief [e.g.,ascites,hydrothorax,esophageal gastricfundus variceal bleeding(EGVB)],cumulative rates of survival,and distributary channel restenosis. The characteristics of the patients surviving ≥ 5 and 5 years were also analyzed.RESULTS: The portosystemic pressure was decreased from 29.0 ± 4.1 mm Hg before TIPS to 18.1 ± 2.9 mm Hg after TIPS(t = 69.32,P 0.05). Portosystemic pressure was decreased and portal hypertension symptoms were ameliorated. During the 5 year followup,the total recurrence rate of resistant ascites or hydrothorax was 7.2%(15/209); 36.8%(77/209) for EGVB; and 39.2%(82/209) for hepatic encephalopathy. The cumulative rates of distributary channel restenosis at 1,2,3,4,and 5 years were 17.2%(36/209),29.7%(62/209),36.8%(77/209),45.5%(95/209) and 58.4%(122/209),respectively. No procedure-related deaths and serious complications(e.g.,abdominal bleeding,hepatic failure,and distant metastasis) occurred. Moreover,Child-Pugh score,portal vein tumor thrombosis,lesion diameter,hepatic arterio-portal fistulas,HCC diagnosed before or after TIPS,stent type,hepatic encephalopathy,and type of other interventional treatments were related to 5 year survival after comparing patient characteristics.CONCLUSION: TIPS combined with other interventional treatments seems to be safe and efficacious in patients with HCC and portal hypertension.     

肝硬化门静脉高压并发症对预后的影响

目的 了解门静脉高压各并发症在失代偿肝硬化患者的发生情况和各并发症对患者预后的影响.方法 选择失代偿期肝硬化患者的病历资料进行登记和随访,根据随访结果,分析患者门静脉高压并发症的发生情况;利用终末期肝病模型(MELD)公式,计算出MELD值并进行分级,同时计算Child-Turcotte-Pugh(CTP)分级,分别分析CTP分级和MELD分级中门静脉高压并发症发生情况和患者生存状况.利用Kaplan-Meier生存分析方法分析门静脉高压并发症对肝硬化患者生存率的影响.利用x2检验和时序性检验比较生存率差别,Cox比例风险回归分析各个并发症对患者生存影响作用的大小.结果 在符合条件的322例失代偿期肝硬化患者中,发生食管胃底静脉曲张破裂出血、肝性脑病、大量腹水、自发性腹膜炎、肝肾综合征Ⅰ型和Ⅱ型的患者病死率分别是45.9%、79.4%、66.7%、100%、100%和84.6%.各并发症的发生基本按CTP分级和MELD值的增加而逐渐升高.经过Kaplan-Meier生存分析,除少量和中量腹水外,各并发症对患者生存率的影响,P值均<0.01,差异均有统计学意义.由Cox回归过程分析出肝性脑病、自发性腹膜炎、肝肾综合征Ⅰ型和Ⅱ型,食管胃底静脉曲张破裂出血和腹水的回归系数分别为0.973、0.928、0.935、0.866、0.464和0.369. 结论 门静脉高压并发症均能对失代偿期肝硬化患者的预后造成明显影响,其中影响程度最大的是肝性脑病.     

Transjugular intrahepatic portosystemic shunt versus open splenectomy and esophagogastric devascularization for portal hypertension with recurrent variceal bleeding

BACKGROUND: Transjugular intrahepatic portosystemic shunt (TIPS) and open splenectomy and esophagogastric devascu-larization (OSED) are widely used to treat patients with portal hypertension and recurrent variceal bleeding (PHRVB). This study aimed to compare the effectiveness between TIPS and OSED for the treatment of PHRVB.METHODS: The data were retrospectively retrieved from 479 cirrhotic patients (Child-Pugh A or B class) with PHRVB, who had undergone TIPS (TIPS group) or OSED (OSED group) between January 1, 2010 and October 31, 2014.RESULTS: A total of 196 patients received TIPS, whereas 283 underwent OSED. Within one month after TIPS and OSED, the rebleeding rates were 6.1% and 3.2%, respectively (P=0.122). Significantly lower incidence of pleural effusion, splenic vein thrombosis, and pulmonary infection, as well as higher hepatic encephalopathy rate, shorter postoperative length of hospital stay, and higher hospital costs were ob-served in the TIPS group than those in the OSED group. Dur-ing the follow-up periods (29 months), significantly higher incidences of rebleeding (15.3% vs 4.6%, P=0.001) and hepatic encephalopathy (17.3% vs 3.9%, P=0.001) were observed in the TIPS group than in the OSED group. The incidence of in-stent stenosis was 18.9%. The survival rates were 91.3% in the TIPS group and 95.1% in the OSED group. The long-term liver function did not worsen after either TIPS or OSED.CONCLUSION: For the patients with liver function in the Child-Pugh A or B class, TIPS is not superior over OSED in terms of PHRVB treatment and rebleeding prevention.     

Distal splenorenal shunt versus transjugular intrahepatic portal systematic shunt for variceal bleeding: a randomized trial

BACKGROUND & AIMS: Variceal bleeding refractory to medical treatment with beta-blockers and endoscopic therapy can be managed by variceal decompression with either surgical shunts or transjugular intrahepatic portal systemic shunts (TIPS). This prospective randomized trial tested the hypothesis that patients receiving distal splenorenal shunts (DSRS) would have significantly lower rebleeding and encephalopathy rates than TIPS in management of refractory variceal bleeding. METHODS: A prospective randomized controlled clinical trial at 5 centers was conducted. One hundred forty patients with Child-Pugh class A and B cirrhosis and refractory variceal bleeding were randomized to DSRS or TIPS. Protocol and event follow-up for 2-8 years (mean, 46 +/- 26 months) for primary end points of variceal bleeding and encephalopathy and secondary end points of death, ascites, thrombosis and stenosis, liver function, need for transplant, quality of life, and cost were evaluated. RESULTS: There was no significant difference in rebleeding (DSRS, 5.5%; TIPS, 10.5%; P = .29) or first encephalopathy event (DSRS, 50%; TIPS, 50%). Survival at 2 and 5 years (DSRS, 81% and 62%; TIPS, 88% and 61%, respectively) were not significantly different (P = .87). Thrombosis, stenosis, and reintervention rates (DSRS, 11%; TIPS, 82%) were significantly (P < .001) higher in the TIPS group. Ascites, need for transplant, quality of life, and costs were not significantly different. CONCLUSIONS: DSRS and TIPS are similarly efficacious in the control of refractory variceal bleeding in Child-Pugh class A and B patients. Reintervention is significantly greater for TIPS compared with DSRS. Because both procedures have equivalent outcomes, the choice is dependent on available expertise and ability to monitor the shunt and reintervene when needed.