Paracentesis with intravenous infusion of albumin as compared with peritoneovenous shunting in cirrhosis with refractory ascites

BACKGROUND. There is no satisfactory treatment for refractory ascites in patients with cirrhosis. Both peritoneovenous shunts and paracentesis have been used, but there is uncertainty about their relative merits. METHODS. We studied 89 patients with cirrhosis and refractory ascites who were randomly assigned to receive either repeated large-volume paracentesis plus intravenous albumin or a LeVeen peritoneovenous shunt. Patients in the paracentesis group in whom recurrent tense ascites developed during follow-up were treated with paracentesis, and those in the peritoneovenous-shunt group with diuretic agents or by the insertion of a new shunt if there was shunt obstruction. RESULTS. During the first hospitalization, ascites was removed in all 41 patients in the paracentesis group and in 44 of the 48 patients in the peritoneovenous-shunt group. The mean (+/- SD) duration of hospitalization in the two groups was 11 +/- 5 and 19 +/- 9 days, respectively (P less than 0.01). There were no significant differences in the number of patients who had complications or died. During follow-up, 37 patients in each group were hospitalized again. In the paracentesis group, the number of rehospitalizations for any reason (174 vs. 97 in the peritoneovenous-shunt group) or for ascites (125 vs. 38) was significantly higher, and the median time to a first readmission for any reason (1 +/- 1 vs. 2 +/- 2 months) or for ascites (2 +/- 2 vs. 8 +/- 17 months) was significantly shorter than in the peritoneovenous-shunt group. The total times in the hospital during follow-up, however, were similar in the two groups (48 +/- 49 and 44 +/- 39 days, respectively). Three patients had obstructions of their peritoneovenous shunts during their first hospitalizations, and 15 patients had a total of 20 obstructions during follow-up. Survival was similar in both groups. CONCLUSIONS. The LeVeen shunt and paracentesis are equally effective in relieving refractory ascites. The former may provide better long-term control of ascites, but shunt occlusion is common and survival is not improved.     

Management of refractory ascites

The development of refractory ascites in approximately 10% of patients with decompensated cirrhosis heralds the progression to a more advanced stage of cirrhosis. Its pathogenesis is related to significant hemodynamic changes, initiated by portal hypertension, but ultimately leading to renal hypoperfusion and avid sodium retention. Inflammation can also contribute to the pathogenesis of refractory ascites by causing portal microthrombi, perpetuating the portal hypertension. Many complications accompany the development of refractory ascites, but renal dysfunction is most common. Management starts with continuation of sodium restriction, which needs frequent reviews for adherence; and regular large volume paracentesis of 5 L or more with albumin infusions to prevent the development of paracentesisinduced circulatory dysfunction. Albumin infusions independent of paracentesis may have a role in the management of these patients. The insertion of a covered, smaller diameter, transjugular intrahepatic porto-systemic stent shunt (TIPS) in the appropriate patients with reasonable liver reserve can bring about improvement in quality of life and improved survival after ascites clearance. Devices such as an automated low-flow ascites pump may be available in the future for ascites treatment. Patients with refractory ascites should be referred for liver transplant, as their prognosis is poor. In patients with refractory ascites and concomitant chronic kidney disease of more than stage 3b, assessment should be referred for dual liver-kidney transplants. In patients with very advanced cirrhosis not suitable for any definitive treatment for ascites control, palliative care should be involved to improve the quality of life of these patients.     

Asymptomatic aneurysmal portosystemic venous shunt: a case report and review of the literature

Spontaneous intrahepatic portosystemic venous shunt (SIPSVS) is relatively rare and not well recognized. Herein, we report 75-year-old female of an aneurysmal portosystemic venous shunt detected by colour Doppler ultrasound in check-up examination. A direct vascular communication between left portal vein and middle hepatic vein was confirmed by CT-angiography. The cause of intrahepatic portosystemic venous shunt is disputed. This abnormality, mainly described in cirrhotic liver and rarely in healthy liver, is usually revealed by hepatic encephalopathy or glycoregulation disorders. However, with improvements in imaging the number of reports of SIPSVS identified incidentally in patients without definite symptoms increasing.     

Treatment of high-risk neuroblastoma with intensive chemotherapy, radiotherapy, autologous bone marrow transplantation, and 13-cis-retinoic acid. Children's Cancer Group.

BACKGROUND: Children with high-risk neuroblastoma have a poor outcome. In this study, we assessed whether myeloablative therapy in conjunction with transplantation of autologous bone marrow improved event-free survival as compared with chemotherapy alone, and whether subsequent treatment with 13-cis-retinoic acid (isotretinoin) further improves event-free survival. METHODS: All patients were treated with the same initial regimen of chemotherapy, and those without disease progression were then randomly assigned to receive continued treatment with myeloablative chemotherapy, total-body irradiation, and transplantation of autologous bone marrow purged of neuroblastoma cells or to receive three cycles of intensive chemotherapy alone. All patients who completed cytotoxic therapy without disease progression were then randomly assigned to receive no further therapy or treatment with 13-cis-retinoic acid for six months. RESULTS: The mean (+/-SE) event-free survival rate three years after the first randomization was significantly better among the 189 patients who were assigned to undergo transplantation than among the 190 patients assigned to receive continuation chemotherapy (34+/-4 percent vs. 22+/-4 percent, P=0.034). The event-free survival rate three years after the second randomization was significantly better among the 130 patients who were assigned to receive 13-cis-retinoic acid than among the 128 patients assigned to receive no further therapy (46+/-6 percent vs. 29+/-5 percent, P=0.027). CONCLUSIONS: Treatment with myeloablative therapy and autologous bone marrow transplantation improved event-free survival among children with high-risk neuroblastoma. In addition, treatment with 13-cis-retinoic acid was beneficial for patients without progressive disease when it was administered after chemotherapy or transplantation.     

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.     

Feature subset selection by genetic algorithms and estimation of distribution algorithms. A case study in the survival of cirrhotic patients treated with TIPS

The transjugular intrahepatic portosystemic shunt (TIPS) is an interventional treatment for cirrhotic patients with portal hypertension. In the light of our medical staff's experience, the consequences of TIPS are not homogeneous for all the patients and a subgroup dies in the first 6 months after TIPS placement. Actually, there is no risk indicator to identify this subgroup of patients before treatment. An investigation for predicting the survival of cirrhotic patients treated with TIPS is carried out using a clinical database with 107 cases and 77 attributes. Four supervised machine learning classifiers are applied to discriminate between both subgroups of patients. The application of several feature subset selection (FSS) techniques has significantly improved the predictive accuracy of these classifiers and considerably reduced the amount of attributes in the classification models. Among FSS techniques, FSS-TREE, a new randomized algorithm inspired on the new EDA (estimation of distribution algorithm) paradigm has obtained the best average accuracy results for each classifier.     

Peritoneovenous shunting as compared with medical treatment in patients with alcoholic cirrhosis and massive ascites. Veterans Administration Cooperative Study on Treatment of Alcoholic Cirrhosis with Ascites

The optimal management of severe ascites in patients with alcoholic cirrhosis has not been defined. in a 5 1/2-year study, we randomly assigned 299 men with alcoholic cirrhosis, who had persistent or recurrent severe ascites despite a standard medical regimen, to receive either intensive medical treatment or peritoneovenous (LeVeen) shunting. We identified three risk groups: Group 1 had normal or mildly abnormal results on liver-function tests, Group 2 had more severe liver dysfunction or previous complications, and Group 3 had severe prerenal azotemia without kidney disease. For the patients who received the medical treatment and those who received the surgical treatment combined, the median survival times were 1093 days in Group 1, 222 days in Group 2, and 37 days in Group 3 (P less than or equal to 0.01) for all comparisons). For all the groups combined, the median time to the resolution of ascites was 5.4 weeks for medical patients and 3.0 weeks for surgical patients (P less than 0.01). Within each risk group, mortality during the initial hospitalization and median long-term survival were similar among patients receiving either treatment. However, the median time to the recurrence of ascites in Group 1 was 4 months in medical patients, as compared with 18 months in surgical patients (P = 0.01); in Group 2 it was 3 months in medical patients as compared with 12 months in surgical patients (P = 0.04). The median duration of hospitalization was longer in medical patients than in surgical patients (6.1 vs. 2.4 weeks in Group 1 [P less than 0.001] and 5.0 vs. 3.1 weeks in Group 2 [P less than 0.01]). Group 3 was too small to permit a meaningful comparison. During the initial hospitalization, the incidence of infections, gastrointestinal bleeding, and encephalopathy was similar among the medical and surgical patients. We conclude that peritoneovenous shunting alleviated disabling ascites more rapidly than medical management. However, survival was closely related to the severity of the illness at the time of randomization and was not altered by shunting.     

Circulating fibroblast growth factor 21 in patients with liver cirrhosis

Fibroblast growth factor 21 (FGF21) is an adipokine and hepatokine, and its hepatic expression is induced in the injured liver. Adiponectin, whose systemic levels are positively correlated with measures of hepatic injury in patients with liver cirrhosis, is a downstream effector of FGF21. The aim of the present study was to identify possible associations of serum FGF21 with measures of liver function in patients with liver cirrhosis. FGF21 was determined by ELISA in serum of 42 patients. FGF21 was not linked to disease severity assessed by the Child–Pugh and MELD score. Levels were not changed in those patients with varices and/or ascites. Systemic FGF21 did not correlate with markers of liver and kidney function, inflammatory proteins or adipokines like adiponectin. Levels in hepatic and portal vein of 37 patients were also measured, but there was no transhepatic FGF21 gradient. Three months after insertion of a transjugular intrahepatic shunt hepatic venous pressure gradient was markedly improved, while FGF21 in serum of these 13 patients was not changed. The present study shows that hepatic release and systemic FGF21 are not linked to measures of liver function in patients with liver cirrhosis.     

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.     

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.     

Feature selection in Bayesian classifiers for the prognosis of survival of cirrhotic patients treated with TIPS

The transjugular intrahepatic portosystemic shunt (TIPS) is a treatment for cirrhotic patients with portal hypertension. A subgroup of patients dies in the first 6 months and another subgroup lives a long period of time. Nowadays, no risk factors have been identified in order to determine how long a patient will survive. An empirical study for predicting the survival rate within the first 6 months after TIPS placement is conducted using a clinical database with 107 cases and 77 variables. Applications of Bayesian classification models, based on Bayesian networks, to medical problems have become popular in the last years. Feature subset selection is useful due to the heterogeneity of the medical databases where not all the variables are required to perform the classification. In this paper, filter and wrapper approaches based on the feature subset selection are adapted to induce Bayesian classifiers (naive Bayes, selective naive Bayes, semi naive Bayes, tree augmented naive Bayes, and k-dependence Bayesian classifier) and are applied to distinguish between the two subgroups of cirrhotic patients. The estimated accuracies obtained tally with the results of previous studies. Moreover, the medical significance of the subset of variables selected by the classifiers along with the comprehensibility of Bayesian models is greatly appreciated by physicians.     

Hepatic arterial infusion of chemotherapy after resection of hepatic metastases from colorectal cancer

BACKGROUND: Two years after undergoing resection of liver metastases from colorectal cancer, about 65 percent of patients are alive and 25 percent are free of detectable disease. We tried to improve these outcomes by treating patients with hepatic arterial infusion of floxuridine plus systemic fluorouracil after liver resection. METHODS: We randomly assigned 156 patients at the time of resection of hepatic metastases from colorectal cancer to receive six cycles of hepatic arterial infusion with floxuridine and dexamethasone plus intravenous fluorouracil, with or without leucovorin, or six weeks of similar systemic therapy alone. Patients were stratified according to previous treatment and the number of liver metastases identified at operation. The study end points were overall survival, survival without recurrence of hepatic metastases, and survival without any metastases at two years. RESULTS: The actuarial rate of overall survival at two years was 86 percent in the group treated with local plus systemic chemotherapy and 72 percent in the group given systemic therapy alone (P=0.03). The median survival was 72.2 months in the combined-therapy group and 59.3 months in the monotherapy group, with a median follow-up of 62.7 months. After two years, the rates of survival free of hepatic recurrence were 90 percent in the monotherapy group and 60 percent in the monotherapy group (P<0.001), and the respective rates of progression-free survival were 57 percent and 42 percent (P=0.07). At two years, the risk ratio for death was 2.34 among patients treated with systemic therapy alone, as compared with patients who received combined therapy (95 percent confidence interval, 1.10 to 4.98; P=0.027), after adjustment for important variables. The rates of adverse effects of at least moderate severity were similar in the two groups, except for a higher frequency of diarrhea and hepatic effects in the combined-therapy group. CONCLUSIONS: For patients who undergo resection of liver metastases from colorectal cancer, postoperative treatment with a combination of hepatic arterial infusion of floxuridine and intravenous fluorouracil improves the outcome at two years.     

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.     

Control of a Candida glabrata prosthetic endovascular infection with posaconazole.

A 63-year-old man with a history of cirrhosis of the liver developed Candida glabrata fungemia after undergoing transjugular intrahepatic portosystemic shunt (TIPS) placement. Treatment with oral fluconazole was initially effective, but when the patient became neutropenic, subsequent blood cultures grew C. glabrata and a thrombus developed, which partially occluded the stent. Despite treatment with fluconazole, blood cultures remained positive for C. glabrata. Treatment with posaconazole resulted in clinical improvement and the patient had only intermittently positive fungal cultures for 6 weeks. A CT scan showed resolution of the inferior vena cava thrombus. Subsequently, the patient developed hepatocellular carcinoma and hepatic encephalopathy and became noncompliant with posaconazole. Blood cultures again became positive for C. glabrata. The patient died a few weeks after the diagnosis of hepatocellular carcinoma, but the cause of death was believed to be worsening liver dysfunction, not C. glabrata infection. Posaconazole had controlled the infection for about 3 months prior to his death. In conclusion, posaconazole may be a useful option in the management of prosthetic endovascular infections caused by C. glabrata.     

Peritoneovenous shunts for palliation of malignant ascites.

BACKGROUND: Malignant ascites may produce a cluster of symptoms that include abdominal distention, early satiety, respiratory embarrassment, impaired mobility, and lethargy, and relief of these symptoms is often difficult to achieve. We report on the placement of peritoneovenous shunts (PVSs) in a group of patients with malignant ascites, with particular reference to the effectiveness and complications of the procedure. PATIENTS AND METHOD: PVSs were inserted in 9 patients with malignant ascites after obtaining their informed consent. The patients were 6 men and 3 women with a median age of 59 years. All had previously been treated with vigorous diuretic therapy or repeated paracentesis or both. Shunt insertion was carried out via a percutaneous approach under local anesthesia. RESULTS: The procedure was well tolerated by all patients. The abdominal distention resolved in all patients, and urine volume increased significantly, demonstrating that the PVS did not affect renal function. The platelet count was reduced, and prothrombin time was prolonged. Two patients had the complication of shunt occlusion, and both patients underwent shunt replacement. There were no lethal complications. Median survival time after PVS placement was 21 days (range, 10 approximately 90 days), and the shunt was functioning at the time of death with good control of ascites in all patients. CONCLUSIONS: Malignant ascites produces troublesome symptoms for patients, who may live for some time. Placement of a PVS is a well-tolerated, relatively minor surgical procedure that can provide excellent control of ascites in most patients selected. The selection of optimal patients requires further study.     

Endoscopic sclerotherapy versus portacaval shunt in patient with severe cirrhosis and acute variceal hemorrhage. Long-term follow-up

In a continuation of a trial for which preliminary results were reported in the Journal two years ago, a total of 64 patients with Child Class C cirrhosis and variceal hemorrhage requiring six or more units of blood were randomly assigned to receive either a portacaval shunt (32 patients) or endoscopic sclerotherapy (32 patients). The duration of initial hospitalization and the total amount of blood transfused during hospitalization were significantly less in the patients receiving sclerotherapy (P less than 0.001). There was no difference in short-term survival (50 percent of the sclerotherapy group were discharged alive, as compared with 44 percent of the shunt-surgery group). Both groups were followed for a mean of 530 days after randomization. Rebleeding from varices, the duration of rehospitalization for hemorrhage, and transfusions received after discharge were all significantly greater in the sclerotherapy group (P less than 0.001). Forty percent of the sclerotherapy-treated patients discharged alive (7 of 16 patients) ultimately required surgical treatment for bleeding varices, despite a mean of 6.1 treatment sessions. Health care costs and long-term survival did not differ significantly between the groups (P greater than 0.05). We conclude that although endoscopic sclerotherapy is as good as surgical shunting for the acute management of variceal hemorrhage in poor-risk patients with massive bleeding, sclerotherapy-treated patients in whom varices are not obliterated and bleeding continues should be considered for elective shunt surgery.     

Feasibility of percutaneous transabdominal portosystemic shunt creation

Evaluation of the anatomic feasibility of the percutaneous transabdominal puncture of selected portal and hepatic veins in patients with cirrhosis was performed. This approach would become the framework for an image-guided robot-assisted needle drive mechanism for use in transjugular intrahepatic portosystemic shunt (TIPS) creation. Retrospective analysis of 10 CT and 14 MRI axial abdominal studies was carried out to determine whether single simultaneous transabdominal puncture of portal and hepatic veins was possible. A necessary modification of the TIPS procedure was tested in an ex vivo porcine model under fluoroscopy. Eighteen of 24 patients (75%) had intrahepatic vascular anatomy amenable to a single transabdominal puncture. Successful catheterization of portal and hepatic veins using a modified approach for TIPS was accomplished in two ex vivo porcine livers. A suitable anatomic approach for modified TIPS is present in a majority of patients with cirrhosis. Feasibility of the technique using this anatomic approach was confirmed in two ex vivo porcine models. This study serves as an initial step in a novel technical approach to TIPS using a new anatomic approach for this procedure.     

The portal vein as a distinct immunological compartment – A comprehensive immune phenotyping study

Advanced liver diseases are associated with impaired intestinal barrier function, which results in bacterial influx via the portal vein to the liver, causing hepatic and systemic inflammation. Little is known about possible concomitant trafficking of immune cells from the intestines to the liver. We therefore performed a comprehensive immunophenotyping study of the portal venous versus peripheral blood compartment in patients with liver cirrhosis who received a transjugular intrahepatic portosystemic stent shunt (TIPS). Our analysis suggests that the portal vein constitutes a distinct immunological compartment resembling that of the intestines, at least in patients with advanced liver cirrhosis. In detail, significantly lower frequencies of naïve CD4⁺ T cells, monocytes, dendritic cells and Vδ2 T cells were observed in the portal vein, whereas frequencies of activated CD4⁺ and CD8⁺ T cells, as well as of mucosa-associated Vδ1 T cells were significantly higher in portal venous compared to peripheral blood. In conclusion, our data raises interesting questions, e.g. whether liver cirrhosis-associated chronic inflammation of the intestines and portal hypertension promote an influx of activated intestinal immune cells like γδ T cells into the liver.     

Splenic transposition is superior to caudal shunt as a model of murine total hepatic ischemia

Murine total hepatic ischemia (THI) followed by reperfusion without shunting of the portal vein induces significant lethality in rodents due to intestinal congestion. Two methods have been promulgated to study THI and reperfusion in mice without intestinal congestion: subcutaneous splenic transposition which creates a portosystemic shunt via epigastric vessels, and a caudal shunt with 30% hepatectomy, which creates a portosystemic shunt via the small remnant of remaining caudal lobe. We compared outcome, inflammatory response and hepatic injury due to THI and reperfusion in these two models. Female C57BL/6 mice underwent ST, caudal shunt or no surgery prior to having 30 min of total hepatic ischemia followed by 60 min of reperfusion. Survival, surgical complications, serum AST/ALT and IL-6 were determined. Apoptotic and necrotic hepatocytes were identified by morphological criteria. Complication rates for the ST and caudal shunt procedures were 6.7 and 20%, respectively. Subsequent mortality rates following THI and 60 min reperfusion were 5.9 and 50% in mice with ST and caudal shunt, respectively. Both groups had elevated serum AST/ALT concentrations. However, in mice undergoing caudal shunt, AST/ALT levels were also significantly increased even without THI. The number of apoptotic hepatocytes after THI and reperfusion in mice following caudal shunt was significantly higher compared with those of ST (P<0.001). Both ST and caudal shunt can be used in models of THI and reperfusion to prevent significant lethality due to intestinal congestion. However, ST is a simple, safe and suitable model, whereas caudal shunt requires manipulation of the liver, and is associated with significant hepatic injury and morbidity.     

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。