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Viatorr覆膜支架。随访12 m。结果 观察组手术时间为(99.5±9.8)min,显著短于对照组【(110.0±8.5)min,P＜0.05】,术后两组门静脉压力均显著降低,但差异无统计学意义(P＞0.05);在术后3 m,两组肝功能指标变化无显著性差异(P>0.05);随访12 m,观察组分流道失效率为1.4%,显著低于对照组的23.3%(P＜0.05);观察组死亡5例(6.8%),对照组死亡6例(8.2%,Log-rank值=0.099,P=0.753)。结论 相对于裸支架和Fluency覆膜双支架,使用Viatorr覆膜支架行TIPS术治疗肝硬化并发门脉高压症患者能有效缩短手术时间,保持分流道通畅,值得进一步观察。     

Interactions between epithelial and mesenchymal cells in intrahepatic peribiliary glands in normal and hepatolithiatic livers

The anatomy and pathology of the intrahepatic peribiliary glands were evaluated. In this study, we ultrastructuraly examined the peribiliary glands of normal and hepatolithiatic livers using common and serial ultrathin section observations. It is well known that these glands proliferate markedly in hepatolithiasis. These glands were composed of several acini surrounded by thickened and multilayered basement membranes, and there were mesenchymal cells (the majority were fibroblasts) in the periacinar fibrous connective tissue. Some cytoplasmic processes of acinar epithelial cells and mesenchymal cells in the periacinar connective tissue were in close contact with each other within the thickened and multilayered basement membranes. Such cell-to-cell interaction was most frequent in cases of hepatolithiasis, in which peribiliary glands proliferated markedly. In hepatolithiatic livers, some unmyelinated nerve fibers or axonal button profiles were in close contact with periacinar mesenchymal cells and also with cytoplasmic processes of glandular epithelial cells. Such contacts were rare in normal livers. These findings suggest that such epithelial and mesenchymal cell interactions and innervations play a part in the normal regulation of peribiliary glands and also in the proliferation of peribiliary galnds in hepatolithiasis.     

Transjugular intrahepatic portosystemic shunt (TIPS) augments hyperinsulinemia in patients with cirrhosis

BACKGROUND/AIMS: Cirrhosis of the liver is characterized by glucose intolerance and hyperinsulinemia. Both increased insulin secretion and decreased insulin clearance appear to contribute to hyperinsulinemia in cirrhotic patients. A decrease in hepatic insulin extraction rate may be due either to hepatocellular dysfunction or to portosystemic shunting with decreased first-pass insulin clearance. METHODS: To specifically address the contribution of portosystemic shunting to the pathogenesis of hyperinsulinemia in cirrhotic patients, we analyzed glycemic control and insulin levels in fasting serum in 23 cirrhotic patients before and after transjugular intrahepatic portosystemic shunt (TIPS). RESULTS: Compared to respective values in healthy controls, C-peptide, insulin and proinsulin concentrations at baseline were increased by 340%, 120% and by 100% in cirrhotic patients (all p<0.05). In cirrhotic patients insulin levels before TIPS averaged 104+/-73 pmol/l and increased by more than 50% to 163+/-118 pmol/l after TIPS (p<0.01), whereas levels of C-peptide and proinsulin showed no significant change. Glucose and fructosamin levels also remained unchanged after TIPS. CONCLUSION: Our data demonstrate that TIPS does not impair glycemic control in cirrhotic patients and that an increase in portosystemic shunting augments hyperinsulinemia, most likely by decreasing hepatic insulin clearance.     

经颈静脉肝内门体分流术后上消化道再出血的临床分析

目的探讨经颈静脉肝内门体分流术（TIPS）术后上消化道再出血的原因及发病机制。方法选择50例行TIPS患者,对其进行观察随访,分析各种因素在术后上消化道再出血中的作用。结果50例行TIPS患者门静脉压力由术前（39．8±9．2）cmH2O（1cmH2O=0．098kPa）降至术后（25．2±5．8）cmH2O,差异有统计学意义（P〈0．05）。14例患者术后出现上消化道再出血,发生率为28％（14／50）,其中3例在术后3d内出现呕吐鲜血,考虑急性胃黏膜病变出血,经内科治疗后短期内出血均得到控制（其中1例患者在术后1年余再发上消化道出血）;12例患者在TIPS术后2年内出现上消化道再出血,出血原因：6例为食管胃底静脉曲张破裂再出血,3例为胃十二指肠溃疡,2例为糜烂性胃炎,1例与凝血异常有关。食管胃底静脉曲张破裂再出血发生率为12％（6／50）。结论TIPS术后并发上消化道再出血的原因主要分为静脉曲张性再出血和非静脉曲张性再出血二种,二者均是TIPS术后重要的再出血原因,静脉曲张性再出血多发生于术后3个月以上,而非静脉曲张性再出血多发生于术后3个月以内。因此对术后患者常规给予质子泵抑制剂保护胃黏膜十分重要。     

肝内胆管囊腺瘤合并囊腺癌误诊1例报告

<正>1病例资料患者,男,37岁,因"间断性发热5个月"入院。既往:患者6个月大时因先天性胆总管囊性扩张症于当地医院行先天性胆总管囊肿切除术。查体:右上腹部压痛,肝区叩击痛。肝功能:ALP 164 U/L,GGT 160 U/L,白蛋白30.6 g/L;CA 199247.70 U/ml。肝胆胰脾多排CT平扫影像诊断:(1)肝左叶外侧段萎缩;(2)肝内胆管多发结石;(3)肝左叶低密度影,建议CT增强检查;(4)肝内胆管略扩张积气;肝门区胆管改变及胆囊区条样气体影(图1)。患者持续高热达39.5℃,结合临床资料拟诊断为肝内胆管结石、化脓性胆管炎、肝脓肿,患者CA199高表达,不除外胆管癌可能。急诊联系超声介入科给予肝内胆管穿刺,引流出脓性胆汁约120 ml,同时行血培养回报:大肠埃希菌;胆汁培养:草绿色链球菌,给予敏感抗生素治疗。抗炎好转后行肝左外叶切除、胆道探查术,术中见肝左外