经颈静脉肝内门腔静脉分流术治疗门静脉高压症

经颈静脉肝内门腔静脉分流术治疗门静脉高压症顾树南陈文庆兰州军区总医院普外科甘肃省兰州市７３００５０ＳｕｂｊｅｃｔｈｅａｄｉｎｇｓＨｙｐｅｒｔｅｎｓｉｏｎ，ｐｏｒｔａｌ／ｓｕｒｇｅｒｙＰｏｒｔａｃａｖａｌｓｈｕｎｔ，ｓｕｒｇｉｃａｌＲｅｖｉｅｗｌｉ...     

经颈静脉肝内门体分流术治疗门静脉高压症

经颈静脉肝内门体分流术(TIPS)是一项专门治疗门静脉高压症的介入治疗新技术.该技术于1969年首先报道,经过30多年的探索与发展,已日臻成熟,现已被广泛用于伴有食管胃底静脉曲张出血,顽固性腹水、Budd-Chiari综合征(BCS)等的门静脉高压症的治疗,并取得了显著疗效.     

经颈静脉肝内门体静脉分流术治疗肝硬化门静脉高压共识意见

<正>门静脉高压症是肝硬化发展过程中的重要病理生理环节,也是肝硬化失代偿期的重要临床表现之一。经颈静脉肝内门体静脉分流术(transjugular intrahepatic portosystemic shunt,TIPS)通过在肝静脉与门静脉之间的肝实质内建立分流道,以微创的方式,从结构上显著降低门静脉阻力,是降低肝硬化患者门静脉压力的关键措施之一。选择恰当病例,可有效减少食管胃静脉曲张再出血和腹水复发等肝硬化并发症,改善肝硬化患者生活质量,减少或延缓对肝移植的需求[1-3]。TIPS应用于临床已有20余年,在经历了一系列观念、技术、器材和联合药物治疗的探索后,目前该技术的有效性和安     

经颈静脉肝内门体分流术治疗肝硬化门静脉高压症临床研究

目的 探讨经颈静脉肝内门体分流术（TIPS）治疗肝硬化门静脉高压症患者的疗效,并总结术中操作关键点,以指导临床治疗。方法 2012年3月~2017年1月诊治的147例肝硬化门静脉高压症患者,术前行肝脏增强CT和肝静脉-门静脉血管CT三维重建,再行TIPS治疗。结果 147例患者均经右颈静脉入路穿刺,操作成功146例（99.3%）;术中发生穿刺胆管、胆囊、肝动脉和肝包膜者分别为5例（3.4%）、2例（1.4%）、4例（2.7%）和8例（5.5%）;2例（1.4%）发生异位栓塞;术前患者干质量（13.0±2.1） kg,空腹血糖（6.4±1.0） mmol/L,空腹胰岛素（20.2±9.3） mU/L,白蛋白（37.4±5.0） g/L,肌酐（59.2±15.9） μmol/L,尿素（5.1±1.6） mmol/L,总胆红素（18.6±5.0） μmol/L,血氨（66.8±24.3） μmol/L;术后3个月,上述指标分别为（15.4±3.2） kg、（5.8±1.4） mmol/L、（15.3±3.3） mU/L、（34.8±3.6） g/L、（58.5±10.9） μmol/L、（4.1±1.6） mmol/L、（27.3±7.2） μmol/L、（70.1±34.4） μmol/L,即术后门静脉压明显下降,干质量、总胆红素水平明显上升,空腹血糖、空腹胰岛素、白蛋白、尿素水平明显下降,差异有统计学意义（P<0.05）;随访12个月,发生支架狭窄31例（21.2%）,肝性脑病25例（17.1%）。结论 TIPS是治疗肝硬化门静脉高压症的可靠方法。手术的重点在于精确的穿刺定位,术前行CT检查和肝静脉-门静脉血管三维重建、术中行门静脉造影有助于保证穿刺操作的成功。     

经颈静脉肝内门体静脉分流术应用近况

经颈静脉肝内门体静脉分流术(Tran-sjugular Intrahepatic Portosystemic Shunt,TIPS)是近几年发展起来的一项新的介入治疗技术。是采用特定的穿刺、扩张器械及血管内支架,在肝内的肝静脉和门静脉大分支之间建立一分流通道,使门静脉血经此通道流入下腔静脉,从而降低门静脉压。     

经颈静脉肝内门体静脉分流术治疗门静脉高压专家共识

经颈静脉肝内门体静脉分流术（TIPS）广泛应用于门静脉高压及其并发症的治疗。近年来,TIPS的适应证、手术方式、术后管理等相关研究都有了新的进展。中华医学会消化病学分会消化微创介入协作组邀请TIPS领域（包括消化科、肝病科、介入放射科、肝胆外科）的相关专家,以循证医学为依据,更新TIPS治疗门静脉高压共识意见,旨在规范和推进TIPS技术在门静脉高压治疗中的临床应用和术后管理。     

经颈静脉肝内门体分流术治疗肝硬化门静脉高压症的预后评估

经颈静脉肝内门体分流术(TIPS)是肝硬化门静脉高压症的一项重要治疗手段,但术后肝衰竭、肝性脑病等并发症一定程度限制了TIPS的临床应用。总结了血清学指标、临床指标、评分系统等TIPS术后预后评估的研究进展及临床价值。临床可根据实际情况选择不同指标或进行综合评估,以提高患者的术后生存率。     

门静脉穿刺造影改良经颈静脉肝内门体分流术治疗门静脉高压上消化道出血

目的探讨经颈静脉肝内门体分流术(TIPS)的改良方法,提高其穿刺准确性和安全性,拓宽TIPS治疗适应证。方法在B超引导下经皮经肝穿刺门静脉右支,成功后引入带金标导管进行门静脉造影、测压、栓塞胃冠状静脉,然后将金标置于门静脉靶穿刺点,引导Rups-100穿刺门静脉,进行门静脉正、侧位造影,确保门静脉穿刺点在距离分叉2 cm以上。有门静脉血栓者用10F鞘管吸出,陈旧血栓用支架旷置。球囊扩张肝实质分流道,置入支架,造影测压。结果20例肝硬化门静脉高压上消化道出血患者用改良TIPS方法治疗均获得成功,上消化道出血即刻得到控制;20例患者共穿刺37针,平均(1.85±0.67) 针;门静脉压力由(30.5±1.1)mm Hg降至(16.9±0.9)mm Hg,治疗前后门静脉压力差异有统计学意义(P<0.05)。4例间接门静脉造影未见显影放弃TIPS治疗的患者,经改良TIPS治疗后也获得成功。20例患者共放置25枚支架,未出现一例与TIPS操作有关的并发症。结论直接门静脉穿刺造影金标定位引导TIPS 操作,可提高TIPS穿刺准确性和安全性,进一步拓宽了TIPS治疗适应证,有利于TIPS技术进一步推广。     

经颈静脉肝内门体分流术对酒精性肝硬化导致门静脉高压的治疗效果与安全性分析

目的分析经颈静脉肝内门体分流术(TIPS)治疗酒精性肝硬化导致门静脉高压的有效性及安全性。方法回顾性总结2006年6月至2011年6月本院30例接受TIPS治疗的酒精性肝硬化导致门静脉高压的患者资料,记录术前及术后门静脉压力、腹水、脾功能亢进、肝功能等指标。随访终点为术后2 a,观察术后并发症包括消化道再出血、支架堵塞、腹水及肝性脑病发生情况,并分析肝性脑病发生与患者临床参数的关系。穿刺前、后门静脉压力差别采用配对t检验分析;Kaplan-Meier方法用于术后临床参数与肝性脑病发生相关性分析。结果 TIPS手术成功率为100%(30/30),门静脉压力术前(37.27±2.52)cm H2O降为术后(24.6±2.58)cm H2O,差异具有统计学意义(P0.05)。术后2 a内,消化道再出血率为3.3%(1/30);腹水治疗有效率达88.9%(16/18);支架狭窄发生率为6.7%(2/30);肝性脑病发生率为40%(12/30)。Kaplan-Meier分析发现患者术前Child-Pugh分级与术后肝性脑病发生密切相关(P=0.04)。结论 TIPS是治疗酒精性肝硬化门静脉高压相关并发症安全有效的微创方法,术前ChildPugh分级是影响患者肝性脑病发生的重要因素。     

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.     

Parallel transjugular intrahepatic portosystemic shunt for controlling portal hypertension complications in cirrhotic patients

AIM: To evaluate the feasibility of a second parallel transjugular intrahepatic portosystemic shunt (TIPS) to reduce portal venous pressure and control complications of portal hypertension.METHODS: From January 2011 to December 2012, 10 cirrhotic patients were treated for complications of portal hypertension. The demographic data, operative data, postoperative recovery data, hemodynamic data, and complications were analyzed.RESULTS: Ten patients underwent a primary and parallel TIPS. Technical success rate was 100% with no technical complications. The mean duration of the first operation was 89.20 ± 29.46 min and the second operation was 57.0 ± 12.99 min. The mean portal system pressure decreased from 54.80 ± 4.16 mmHg to 39.0 ± 3.20 mmHg after the primary TIPS and from 44.40 ± 3.95 mmHg to 26.10 ± 4.07 mmHg after the parallel TIPS creation. The mean portosystemic pressure gradient decreased from 43.80 ± 6.18 mmHg to 31.90 ± 2.85 mmHg after the primary TIPS and from 35.60 ± 2.72 mmHg to 15.30 ± 3.27 mmHg after the parallel TIPS creation. Clinical improvement was seen in all patients after the parallel TIPS creation. One patient suffered from transient grade I hepatic encephalopathy (HE) after the primary TIPS and four patients experienced transient grade I-II after the parallel TIPS procedure. Mean hospital stay after the first and second operations were 15.0 ± 3.71 d and 16.90 ± 5.11 d (P = 0.014), respectively. After a mean 14.0 ± 3.13 mo follow-up, ascites and bleeding were well controlled and no stenosis of the stents was found.CONCLUSION: Parallel TIPS is an effective approach for controlling portal hypertension complications.     

采用覆膜支架行经颈静脉肝内门体静脉分流术治疗原发性肝癌并门静脉高压46例疗效分析

目的：探讨使用覆膜支架行经颈静脉肝内门体静脉分流术（TIPS）治疗原发性肝癌合并门静脉高压的临床疗效。方法回顾性分析46例使用覆膜支架行 TIPS 治疗原发性肝癌合并门静脉高压症患者的临床资料,分析患者术后肝功能指标变化、分流道通畅率、再出血率、肝性脑病、腹水、胃肠道症状变化,以及术后生存期、死亡原因等。手术前后组间的计量资料比较采用配对 t 检验。采用生存曲线分析支架通畅率、肝性脑病发生率和生存率。结果手术后门静脉压力[（16．2±4．6）mmHg （1 mmHg＝0．133 kPa）]较手术前[（28．3±5．1）mmHg]明显降低,差异有统计学意义（t ＝21．30,P ＜0．05）。术后7 d 肝功能 Child-Pugh 评分为（6．9±1．5）分,与术前[（6．8±1．8）分]相比差异无统计学意义（P ＞0．05）。术后3、6、12、24、36个月覆膜支架分流道的累积通畅率分别是100．0％、95．6％、93．5％、91．3％、91．3％。肝性脑病的累积发生率分别为6．5％、8．7％、13．0％、17．4％、26．1％。累积生存率分别是95．7％、82．6％、67．4％、43．5％、32．6％。10例难治性腹水患者术后积液量均有不同程度减少,消化道不适症状明显减轻。结论对伴有门静脉高压的原发性肝癌患者,如果发生上消化道出血或顽固性腹水,使用覆膜支架行 TIPS 可有效降低门静脉压力,预防再发出血,减少腹水量。     

经颈内静脉肝内门体分流术治疗肝硬化门脉高压症56例

目的:探讨经颈内静脉肝内门体分流术 (transjugular intrahepatic portosystemic shunt, TIPS)治疗肝硬化门脉高压症的临床疗效及并发症．方法:肝硬化并发门脉高压症患者56例,行 TIPS术,支架置入前后测量门静脉主干压力, 测定门静脉、脾静脉内径,测定门静脉、分流道血流速度;检测外周血象．结果:TIPS术成功率100％,门脉主干压 (cmH2O)24．5±4．2(P<0．01 vs 术前的45．8± 3．6),门静脉内径及脾静脉内径(cm)分别为 1．28±0．095和0．96±0．064(P<0．01 vs术前的 1．62±0．074和1．28±0．032),门脉主干血流速度(cm／s)48．0±17．6(P<0．01 vs术前的13．2± 3．5),分流道血流速度(cm／s)164．0±58．8．脾功能亢进患者30例,WBC(×109／L),PLT(× 109/L),HGB(×g／L)分别为3．92±0．76,80．74± 16．82,118．20±10．24(P<0．01 vs术前的2．65± 0．58,42．56±12．34,86．52±12．68)．食道胃底静脉曲张,腹水等临床症状明显好转．常见并发症有肝性脑病,支架狭窄及闭塞．结论:TIPS是一种治疗肝硬化门脉高压症的有效方法,他能有效地降低门脉压,控制食道、胃底静脉曲张破裂出血．     

Effect of transjugular intrahepatic portosystemic shunt on pulmonary gas exchange in patients with portal hypertension and hepatopulmonary syndrome

AIM: To assess the impact of transjugular intrahepatic portosystemic shunt (TIPS) on pulmonary gas exchange and to evaluate the use of TIPS for the treatment of hepatopulmonary syndrome (HPS ). METHODS: Seven patients, three of them with advanced HPS, in whom detailed pulmonary function tests were performed before and after TIPS placement at the University of Alabama Hospital and at the Hospital Clinic, Barcelona, were considered. RESULTS: TIPS patency was confirmed by hemodynamic evaluation. No changes in arterial blood gases were observed in the overall subset of patients. Transient arterial oxygenation improvement was observed in only one HPS patient, early after TIPS, but this was not sustained 4 mo later. CONCLUSION: TIPS neither improved nor worsened pulmonary gas exchange in patients with portal hypertension. This data does not support the use of TIPS as a specific treatment for HPS. However, it does reinforce the view that TIPS can be safely performed for the treatment of other complications of portal hypertension in patients with HPS.     

Targeted puncture of left branch of intrahepatic portal vein in transjugular intrahepatic portosystemic shunt to reduce hepatic encephalopathy

BACKGROUND Transjugular intrahepatic portosystemic shunt(TIPS) is currently used for the treatment of complications of portal hypertension. The incidence of hepatic encephalopathy(HE) remains a problem in TIPS placement. It has been reported that the right branch mainly receives superior mesenteric venous blood while the left branch mainly receives blood from the splenic vein. We hypothesized that targeted puncture of the left portal vein would divert the non-nutritive blood from the splenic vein into the TIPS shunt; therefore, targeted puncture of the left branch of the intrahepatic portal vein during TIPS may reduce the risk of HE.AIM To evaluate the influence of targeted puncture of left branch of portal vein in TIPS on HE.METHODS A retrospective analysis of 1244 patients with portal-hypertension-related complications of refractory ascites or variceal bleeding who underwent TIPS from January 2000 to January 2013 was performed. Patients were divided into group A(targeting left branch of portal vein, n = 937) and group B(targeting right branch of portal vein, n = 307). TIPS-related HE and clinical outcomes were analyzed.RESULTS The symptoms of ascites and variceal bleeding disappeared within a short time.By the endpoint of follow-up, recurrent bleeding and ascites did not differ significantly between groups A and B(P = 0.278, P = 0.561, respectively).Incidence of HE differed significantly between groups A and B at 1 mo(14.94% vs36.80%, χ~2 = 4.839, P = 0.028), 3 mo(12.48% vs 34.20%, χ~2 = 5.054, P = 0.025), 6 mo(10.03% vs 32.24%, χ~2 = 6.560, P = 0.010), 9 mo(9.17% vs 31.27%, χ~2 = 5.357, P =0.021), and 12 mo(8.21% vs 28.01, χ~2 = 3.848, P = 0.051). There were no significant differences between groups A and B at 3 years(6.61% vs 7.16%, χ~2 = 1.204, P =0.272) and 5 years(5.01% vs 6.18%, χ~2 = 0.072, P = 0.562). The total survival rate did not differ between groups A and B(χ~2 = 0.226, P = 0.634, log-rank test).CONCLUSION Targeted puncture of the left branch of the intrahepatic portal vein during TIPS may reduce the risk of HE but has no direct influence on prognosis of portalhypertension-related complications.     

Body composition changes after transjugular intrahepatic portosystemic shunt in patients with cirrhosis

AIM:To investigate the effect of transjugular intra-hepatic porto-systemic shunt (TIPS) on malnutrition in portal hypertensive cirrhotic patients.METHODS: Twenty-one patients with liver cirrhosis and clinical indications for TIPS insertion were investigated before and 1, 4, 12, 52 wk after TIPS. For each patient we assayed body composition parameters [dry lean mass, fat mass, total body water (TBW)], routine liver and kidney function tests, and free fatty acids (FFA). Glucose and insulin were measured for t...