A case of successful treatment of stomal variceal bleeding with transjugular intrahepatic portosystemic shunt and coil embolization

Variceal bleeding from enterostomy site is an unusual complication of portal hypertension. The bleeding, however, is often recurrent and may be fatal. The hemorrhage can be managed with local measures in most patients, but when these fail, surgical interventions or portosystemic shunt may be required. Herein, we report a case in which recurrent bleeding from stomal varices, developed after a colectomy for rectal cancer, was successfully treated by placement of transjugular intrahepatic portosystemic shunt (TIPS) with coil embolization. Although several treatment options are available for this entity, we consider that TIPS with coil embolization offers minimally invasive and definitive treatment.     

经颈静脉肝内门体静脉分流研究进展与肝脏静脉系统可视化

门静脉高压症的外科治疗虽已步入肝移植时代，但由于肝移植手术的供肝有限，费用昂贵及技术有待进一步完善等原因，非手术的血管介入治疗具有着现实的应用价值和临床地位。     

Three-dimensional reconstruction of paracentesis approach in transjugular intrahepatic portosystemic shunt

To establish a digital transjugular intrahepatic portosystemic shunt (TIPS) model and provide morphological data for radiological diagnosis and interventional radiology to reduce portal vein pressure, 400 serial sectional images from the internal jugular vein superior margin to the lower edge of the liver were chosen from the Chinese Visible Human dataset. Surface and volume reconstructions were performed using 3D-DOCTOR 3.5 software on an ordinary personal computer. Volume and surface renderings were employed to perform data segmentation and image edge detection for reconstruction of the internal jugular vein, brachiocephalic vein, superior vena cava, heart, inferior vena cava, hepatic vein, and portal vein for computerized 3D reconstruction of the TIPS pathway and construction of a 3D visible model of different structures along it. The model can also display pathway and distribution characteristics and interactively show the spatial structural relationships between intrahepatic venous lines from any position and angle, plus complete data acquisition for any range and angle for 3D reconstruction with stereopsis and measurements using any visualization platform. The digital reconstruction of the TIPS pathway correctly reflected the complicated anatomic structural characteristics and spatial adjacency relationships between intrahepatic venous lines, providing a reference 3D morphology for image diagnostics and interventional TIPS therapy.     

经颈静脉肝内门体静脉分流术对脾切除术后门静脉高压患者治疗的有效性与安全性

目的:分析经颈静脉肝内门体静脉分流术(transjugular intrahepatic portosystemic shunt,TIPS)对行脾切除术后的门静脉高压治疗的有效性与安全性.方法:选取2005年5月至2010年5月于空军总医院放射介入科接受TIPS治疗的68名行脾切除术的门静脉高压患者为病例组,以同期接受TIPS治疗的未行脾切除术的门静脉高压患者68例为对照组,分析比较两组患者的手术成功率、治疗前后肝功能、血小板及门静脉压力的变化情况,并记录两组患者不良事件的发生情况.结果:病例组TIPS成功率为97.06％(66/68),对照组TIPS成功率为100％(68/68),两组比较差异无统计学意义(x2=0.04,P=0.15);两组患者手术前、后肝功能及血小板计数比较差异无统计学意义;病例组与对照组术后PLT计数分别降至45.4±8.6,59.4±15.8,差异有统计学意义(P＜0.05);病例组术后ALB降至29.8±6.3,差异有统计学意义(P＜0.05);两组患者手术前后门静脉压力比较无统计学差异,术后病例组与对照组分别降至27.3±5.4,28.5±4.3,差异有统计学意义(P＜0.05);随访观察12～60个月,病例组分流道失效率病例组高于对照组(22.73％ vs.8.82％,P=0.04),再出血率及肝性脑病发生率比较,差异无统计学意义.结论:已行脾断流术的患者接受TIPS治疗,仍可获得满意的临床疗效,但术后发生分流道失效的风险较高,因此临床应用时应注意前瞻性预防,以获得较满意的效益安全比.     

数字化虚拟解剖学技术在经颈静脉肝内门腔静脉分流术和直接性门腔分流术中的应用

目的:利用影像数字化虚拟解剖学技术,经颈静脉肝内门腔静脉分流术(TIPSS)、直接性门腔静脉分流术(DIPS)模拟穿刺途径与水平垂线间角度进行测量,以期为临床TIPSS、DIPS术提供解剖学资料.方法:选取上腹部64-MSCT扫描正常组共40例,肝硬化组16例.用智能追踪技术启动扫描,并将所得数据在GE ADW4.2工作站进行处理.结果:正常组与肝硬化Child-Pugh A、B分级组TIPSS模拟穿刺途径与垂线间角度,除肝中静脉3cm与肝右静脉1cm间增大外,其余均呈减小趋势;DIPS术中下等分线模拟穿刺途径与垂线角度大于上等分线相应穿刺途径角度.门静脉左支1cm至上等分线的模拟穿刺途径与垂线角度在正常组与肝硬化Child-Pugh A、B分级组间差异有统计学意义.结论:影像数字化虚拟解剖学技术有助于提供活体功能状态下TIPSS、DIPS相关解剖学资料.可根据模拟途径与水平垂线间角度在体外调整穿刺套针的曲度.     

Pathomorphology of the transjugular portosystemic shunt

An interventional radiological procedure TIPS (transjugular portosystemic shunt) assists in the decrease of portal hypertension. Portal blood is conducted via the hepatic vein into the lower vena cava. Blood drainage is performed via non-vascular formation, i.e. by the channel created within the liver parenchyma (shunt). Histological changes (maturation) within the wall of an artificially formed blood conducting channel were studied on the base of examination of the set of 38 autopsy cases with the placed TIPS (25 males and 13 females, ages ranging from 22-81 years). Maturation course can be divided into three periods. The first stage is characterised by the presence of alternative changes mainly within the liver parenchyma surrounding the shunt. Reparative changes pass through the second stage with the predominance of liver cell debris removal and organisation of fibrin remnants. Consolidation changes dominate the third stage with the development of so-called neointima and giant-cell reaction around the stent struts. In three cases of the acute period of stent placement a new, so far not described specific phenomenon of compressive fusiform hepatocellular remodellation was found within the nodules of hepatocytes exposed to the pressure of resilient stent struts. Neointima is a non-thrombogenous structure participating on the shunt patency. It is possible to judge approximately the time of stent placement according to the histologically estimated level of shunt wall maturation. TIPS is a long-lasting supplement conduit between the portal and systemic blood circulation. Contrary to the easily reconstructable formal pathogenesis of histological changes, the problems of causal pathogenesis of the neointima challenge mainly the interest of laboratories involved in basic science.     

The role of transjugular intrahepatic portosystemic shunt in patients with portal hypertension: Advantages and pitfalls

Transjugular intrahepatic portosystemic shunt (TIPS) is an effective interventional procedure to relieve portal hypertension, which is a main mechanism for the development of complications of liver cirrhosis (LC), such as variceal hemorrhage, ascites, and hepatorenal syndrome. However, the high incidence of adverse events after TIPS implementation limits its application in clinical practice. Esophageal variceal hemorrhage is one of the major indications for TIPS. Recently, preemptively performed TIPS has been recommended, as several studies have shown that TIPS significantly reduced mortality as well as rebleeding or failure to control bleeding in patients who are at high risk of treatment failure for bleeding control with endoscopic variceal ligation and vasoactive drugs. Meanwhile, recurrent ascites is another indication for TIPS with a proven survival benefit. TIPS may also be considered as an effective treatment for other LC complications, usually as an alternative therapy. Although there are concerns about the development of hepatic encephalopathy and hepatic dysfunction after TIPS implementation, careful patient selection using prognostic scores can lead to excellent outcomes. Assessments of cardiac and renal function prior to TIPS may also be considered to improve patient prognosis.     

Clinical outcomes of transjugular intrahepatic portosystemic shunt for portal hypertension: Korean multicenter real-practice data

Background/Aims

This retrospective study assessed the clinical outcome of a transjugular intrahepatic portosystemic shunt (TIPS) procedure for managing portal hypertension in Koreans with liver cirrhosis.

Methods

Between January 2003 and July 2013, 230 patients received a TIPS in 13 university-based hospitals.

Results

Of the 229 (99.6%) patients who successfully underwent TIPS placement, 142 received a TIPS for variceal bleeding, 84 for refractory ascites, and 3 for other indications. The follow-up period was 24.9±30.2 months (mean±SD), 74.7% of the stents were covered, and the primary patency rate at the 1-year follow-up was 78.7%. Hemorrhage occurred in 30 (21.1%) patients during follow-up; of these, 28 (93.3%) cases of rebleeding were associated with stent dysfunction. Fifty-four (23.6%) patients developed new hepatic encephalopathy, and most of these patients were successfully managed conservatively. The cumulative survival rates at 1, 6, 12, and 24 months were 87.5%, 75.0%, 66.8%, and 57.5%, respectively. A high Model for End-Stage Liver Disease (MELD) score was significantly associated with the risk of death within the first month after receiving a TIPS (P=0.018). Old age (P<0.001), indication for a TIPS (ascites vs. bleeding, P=0.005), low serum albumin (P<0.001), and high MELD score (P=0.006) were associated with overall mortality.

Conclusions

A high MELD score was found to be significantly associated with early and overall mortality rate in TIPS patients. Determining the appropriate indication is warranted to improve survival in these patients.     

A comparison of paracentesis and transjugular intrahepatic portosystemic shunting in patients with ascites

BACKGROUND: In patients with cirrhosis and ascites, creation of a transjugular intrahepatic portosystemic shunt may reduce the ascites and improve renal function. However, the benefit of this procedure as compared with that of large-volume paracentesis is uncertain. METHODS: We randomly assigned 60 patients with cirrhosis and refractory or recurrent ascites (Child-Pugh class B in 42 patients and class C in 18 patients) to treatment with a transjugular shunt (29 patients) or large-volume paracentesis (31 patients). The mean (+/-SD) duration of follow-up was 45+/-16 months among those assigned to shunting and 44+/-18 months among those assigned to paracentesis. The primary outcome was survival without liver transplantation. RESULTS: Among the patients in the shunt group, 15 died and 1 underwent liver transplantation during the study period, as compared with 23 patients and 2 patients, respectively, in the paracentesis group. The probability of survival without liver transplantation was 69 percent at one year and 58 percent at two years in the shunt group, as compared with 52 percent and 32 percent in the paracentesis group (P=0.11 for the overall comparison, by the log-rank test). In a multivariate analysis, treatment with transjugular shunting was independently associated with survival without the need for transplantation (P=0.02). At three months, 61 percent of the patients in the shunt group and 18 percent of those in the paracentesis group had no ascites (P=0.006). The frequency of hepatic encephalopathy was similar in the two groups. Of the patients assigned to paracentesis in whom this procedure was unsuccessful, 10 received a transjugular shunt a mean of 5.5+/-4 months after randomization; 4 had a response to this rescue treatment. CONCLUSIONS: In comparison with large-volume paracentesis, the creation of a transjugular intrahepatic portosystemic shunt can improve the chance of survival without liver transplantation in patients with refractory or recurrent ascites.     

The secondary prophylactic efficacy of beta-blocker after endoscopic gastric variceal obturation for first acute episode of gastric variceal bleeding

Background/Aims

The most appropriate treatment for acute gastric variceal bleeding (GVB) is currently endoscopic gastric variceal obturation (GVO) using Histoacryl®. However, the secondary prophylactic efficacy of beta-blocker (BB) after GVO for the first acute episode of GVB has not yet been established. The secondary prophylactic efficacy of BB after GVO for the first acute episode of GVB was evaluated in this study.

Methods

Ninety-three patients at Soonchunhyang University Hospital with acute GVB who received GVO using Histoacryl® were enrolled between June 2001 and March 2010. Among these, 42 patients underwent GVO alone (GVO group) and 51 patients underwent GVO with adjuvant BB therapy (GVO+BB group). This study was intended for patients in whom a desired heart rate was reached. The rates of rebleeding-free survival and overall survival were calculated for the two study groups using Kaplan-Meyer analysis and Cox''s proportional-hazards model.

Results

The follow-up period after the initial eradication of gastric varices was 18.14±25.22 months (mean±SD). During the follow-up period, rebleeding occurred in 10 (23.8%) and 21 (41.2%) GVO and GVO+BB patients, respectively, and 39 patients died [23 (54.8%) in the GVO group and 16 (31.4%) in the GVO+BB group]. The mean rebleeding-free survival time did not differ significantly between the GVO and GVO+BB groups (65.40 and 37.40 months, respectively; P=0.774), whereas the mean overall survival time did differ (52.54 and 72.65 months, respectively; P=0.036).

Conclusions

Adjuvant BB therapy after GVO using Histoacryl® for the first acute episode of GVB could decrease the mortality rate relative to GVO alone. However, adjuvant BB therapy afforded no benefit for the secondary prevention of rebleeding in GV.     

The comparison of esophageal variceal ligation plus propranolol versus propranolol alone for the primary prophylaxis of esophageal variceal bleeding

Background/Aims

To investigate the efficacy and longterm outcome of esophageal variceal ligation (EVL) plus propranolol in comparison with propranolol alone for the primary prophylaxis of esophageal variceal bleeding.

Methods

A total of 504 patients were retrospectively enrolled in this study. 330 patients were in propranolol group (Gr1) and 174 patients were in EVL plus propranolol group (Gr2). The endpoints of this study were esophageal variceal bleeding and mortality. Association analyses were performed to evaluate bleeding and mortality between Gr1 and Gr2.

Results

EVL was more applied in patients with high risk, such as large-sized varices (F2 or F3) or positive red color signs. Total 38 patients had bleeds, 32 in Gr1 and 6 in Gr2. The cumulative probability of bleeding at 120 months was 13% in Gr1 versus 4% in Gr2 (P=0.04). The predictive factors of variceal bleeding were red color signs (OR 2.962, P=0.007) and the method of propranolol plus EVL (OR 0.160, P=0.000). 20 patients died in Gr1 and 12 in Gr2. Mortality rates are similar in the two groups compared, 6.7% in Gr1 and 6.9% in Gr2. The cumulative probability of mortality at 120 months was not significantly different in the two groups (7% in Gr1, 12% in Gr2, P=0.798). The prognostic factors for mortality were age over 50 (OR 5.496, P=0.002), Child-Pugh class B (OR 3.979, P=0.001), and Child-Pugh class C (OR 10.861, P=0.000).

Conclusions

EVL plus propranolol is more effective than propranolol alone in the prevention of the first variceal bleeding in patients with liver cirrhosis.     

Prognostic factors and long-term survival in breast cancer in a defined urban population

During the years 1945-1965 461 women in the city of Turku, Southwestern Finland, were diagnosed as having a biopsy-verified breast cancer. Four-hundred and thirty-nine patients (95%) with complete clinicopathologic data have now been followed up for a mean of 28 years (range from 22 to 42 years) or until death. The survival rate corrected for intercurrent deaths was 44%, 35%, and 34% 10, 20, and 30 years after the diagnosis, respectively. Only 1.2% of all deaths caused by breast cancer occurred more than 20 years after the diagnosis, and therefore about one third of the patients are likely to be cured. Fifty-six (12.8%) patients developed a second primary breast cancer or cancer of other sites. Survival of the patients diagnosed in the 1960s was better than that of the patients diagnosed earlier (p = 0.02), but the relative percentage of prognostically unfavorable poorly differentiated (Gr III) cancers became smaller with time (p = 0.009). Axillary nodal status was the most important independent prognostic factor for the 342 patients with an operable, unilateral, and invasive breast cancer in Cox's multivariate analysis (p less than 0.001), followed by histologic grade, type of tumor margin, the primary tumor size (p less than 0.001), and the extent of tumor necrosis (p = 0.003). Histologic type, mitotic count, nuclear pleomorphism, extent of tubule formation, amount of elastin, and extent of intraductal tumor growth were also significant prognostic factors in a univariate analysis.     

经股静脉行肝内门-体静脉分流插管术的回归方程及临床意义

目的　为临床经股静脉肝内门 体静脉分流插管术提供解剖学依据。方法　在 4 5具成人尸体上观测了双侧股静脉穿刺点至肝中静脉的长度 ,与胸骨颈静脉切迹到耻骨联合上缘的距离作相关回归分析。结果　从左侧股静脉穿刺点至肝中静脉的长度为 (3 9 83± 3 87)cm ,直线回归方程为 ^y =3 0 9± 0 71x;P <0 0 2 5 ;从右侧股静脉穿刺点至肝中静脉的长度为(3 8 4 9± 3 60 )cm ,直线回归方程为 ^y =3 0 3± 0 67x ;P <0 0 1;左、右侧股静脉与髂外、髂总静脉的夹角分别为 163 2 2°± 5 5 7°和 166 0 0°± 5 10° ,左、右侧髂外、髂总静脉与下腔静脉的夹角分别为 14 6 4 4°± 9 0 7°和 15 8 0 0°± 5 2 3°。结论　经右侧股静脉插管较左侧更为有利 ,可根据方程计算出从股静脉穿刺点到肝中静脉的长度     

肺移植后影响患者长期生存的危险因素

背景：国内肺移植开展数量较少,移植后长期生存时间较其他器官移植短,其原因尚不完全清楚。 目的：分析影响肺移植后患者长期生存因素。 方法：回顾分析61例终末期肺疾病患者接受肺移植的临床资料,根据随访生存时间将患者分为两组。观察组生存时间>3年29例,对照组生存时间<1年32例,对两组患者的一般特征、术式(单、双肺移植)、肺动脉压力、是否应用体外膜氧合等进行多因素逻辑回归分析比较。 结果与结论：统计学分析显示,年龄(≥50岁)、肺移植前肺动脉高压、急性排斥和肺部严重感染是影响患者肺移植后长期生存的独立风险因素。提示肺移植治疗终末期肺病,选择合适肺移植患者,移植前控制肺动脉压,移植中严格把握体外膜氧合转流适应证,移植后预防肺部感染,严格免疫抑制剂治疗是延长患者生存时间重要措施。     

64层螺旋CT在门腔分流模拟穿刺角度测量中的应用及其意义

目的通过对非肝病患者及肝硬化患者模拟穿刺途径与门静脉右支及肝中、肝右静脉夹角的测量,以期为肝内门腔分流提供形态学资料。方法选取上腹部64-MSCT扫描非肝病被检查组共40例;肝硬化组符合纳入标准14例。用智能追踪技术启动扫描。并将所得数据在GEADW4.2工作站进行处理。结果无论正常组或肝硬化Child-PughA、B分级组,肝中、肝右静脉1、2、3cm和门静脉右支1、2cm间的模拟穿刺途径与肝静脉间夹角平均值呈减小趋势,而模拟穿刺途径与门静脉右支间夹角则依次增大。按照α=0.05标准认为正常组与肝硬化Child-PughA、B分级组模拟穿刺途径与肝中、肝右静脉和门静脉间夹角没有显著差异。结论TIPSS模拟穿刺途径与肝中、肝右静脉和门静脉右支间夹角变化方向相反。在肝中静脉2cm与门静脉2cm间穿刺较为适合。     

The long-term treatment of peptic ulcer after a bleeding episode

We have studied 51 consecutive patients bleeding from peptic ulcer which was duodenal (D.U.) in 30, gastric in 17 (G.U.), anastomotic in 3 (Billroth 2), and oesophageal in 1 of them. One patient with G.U. was sent for surgery and 2 patients with D.U. died early; the others recovered through medical treatment and the ulcer healed after 6-8 weeks of treatment with ranitidine in 46 out of 48 patients. Subsequently, all the healed patients have been treated with ranitidine (150 mg at bedtime) for 6 months; by this time a new endoscopy showed an erosive antral gastritis in 2 patients with G.U. and 2 recurrences of D.U. Then the patients and their family doctors were invited to choose between the interruption of the treatment and its prolongation. 8 patients with previous G.U. preferred to stop treatment, and up to 1-2 years they did not show any recurrence; the remaining 5 patients carried on the maintenance treatment, and up to one year one of them showed an erosive antral gastritis. 15 patients with previous D.U. stopped the treatment and 5 of them after 1-24 months presented a recurrence with a new haemorrhage; 8 patients chose to continue the treatment and none of them for 6-24 months had recurrence. The limited number of the patients obviously does not allow a sound conclusion, but a trend is clearly seen which favours a prolonged maintenance treatment in patients with D.U. which has bled.     

食管胃静脉曲张供血与分流血管CT三维成像研究

目的:应用64层螺旋CT肝门静脉成像(CTPV)技术,探讨食管胃静脉曲张供血血管与分流血管解剖特征.方法:收集并分析我院64层螺旋CT肝门静脉成像及胃镜检查证实的食管胃静脉曲张50例.先常规平扫,后三期增强扫描,二维重建方法采用MIP、VR、MPR.结果:本组50例,食管静脉曲张几乎全部由胃左静脉供血,单纯南胃左静脉前支供血57.8%(26例),伴有食管旁静脉曲张82.2%(37例);胃底静脉曲张由单纯胃左静脉供血61.1%(22例),由胃短、胃后静脉供血11.1%(4例),由胃短、胃后、胃左静脉双蕈供血27.8%(10例).脾/胃-肾静脉分流20%(10例).结论:64层螺旋CT肝门静脉成像能立体、清晰地显示食管胃静脉曲张的供血与分流血管,对临床选择治疗方案具有重要价值.