A prospective evaluation of changes in neuropsychological and liver function tests following transjugular intrahepatic portosystemic stent-shunt

Background/Aims: This study was designed to assess changes in: (a) neuropsychological tests, measures of memory, quality of life and scores for anxiety and depression; (b) liver function tests; and (c) the relationship between these following transjugular intrahepatic portosystemic stent-shunt.Methods: Twenty-nine patients undergoing transjugular intrahepatic portosystemic stent-shunt for recurrent variceal haemorrhage, 12 matched patients with cirrhosis and variceal haemorrhage manage with variceal band ligation and 16 normal controls were studied. Patients in any of the groups who were clinically encephalopathic were excluded from the study. Serial changes in the conventional liver function tests and Indocyanine green clearance, and psychometric function (Hospital Anxiety Depression Scale, Rivermead Behavioral Memory Test, Quality of Life and the memory and reaction sub-tests of the Cambridge Automated Neuropsychological Test Assessment Battery) were measured prior to and 1, 3, 9 and 15 months following transjugular intrahepatic portosystemic stent-shunt.Results: Over a mean follow up of 9.1 months in the transjugular intrahepatic portosystemic stent-shunt group (range 3–28), one patient (3%) developed clinically detectable encephalopathy. Sixty-seven percent of patients with cirrhosis showed evidence of subclinical encephalopathy as compared with the control population. Significant deterioration occurred in the reaction sub-tests of the Cambridge Automated neuropsychological Test Assessment Battery in patients, both in the transjugular intrahepatic portosystemic stent-shunt group and the controls with cirrhosis, during follow up. Transjugular intrahepatic portosystemic stent-shunt was followed by significant deterioration in levels of anxiety and psychological component of the quality of life. The Rivermead Behavioural Memory Test and the memory sub-test of the Cambridge Automated Neurpsychological Test Assessment Battery did, however, improve significantly at 1 and 15 months after transjugular intrahepatic portosystemic stent-shunt, respectively. Serum alanine aminotransferase, bilirubin and indocyanine green clearance deteriorated significantly following transjugular intrahepatic portosystemic stent-shunt (p<0.001, p<0.001 and p<0.0001, respectively). Significant correlation was observed between changes in the indocyanine green clearance and changes in the complex and simple reaction time subtests of the Cambridge Automated Neuropsychological Test Assessment Battery (r=0.6 and r=0.66, respectively).Conclusions: The results of this study showed that about 67% of patients with cirrhosis were subclinically encephalopathic and that temporary deterioration occurred in the Cambridge Automated Neuropsychological Test Assessment Battery during follow up, both in patients having transjugular intrahepatic portosystemic stent-shunt and in the controls with cirrhosis. These parallel the changes in the liver function tests and indocyanine green clearance. Temporary deterioration was also observed in the Quality of Life and Hospital Anxiety Depression Scale in the transjugular intrahepatic portosystemic stent-shunt group, although the measures of memory improved. Further studies should address the biochemical mechanisms of these changes and the role of prophylactic measures.     

TIPSS与PSE并用的价值及可行性初探

探讨ＴＩＰＳＳ与ＰＳＥ并用的可行性及价值。材料与方法；ＴＩＰＳＳ与ＰＳＥ同时施竽者２例，其余４例在ＴＩＰＳＳ复查时进行，直测ＰＳＥ前后门脉奔放 力。检测ＰＳＥ前后白细胞，血小板数值，观察术后并发症情况，结果：ＴＩＰＳＳ及ＰＳＥ后消化道出血停止。门脉压力平均下降５．６ｃｈＨ２Ｏ，脾机能亢进基本缓解，血小板，白细胞均明显上升。     

TIPSS术后并发症的成因分析及防治

经颈静脉肝内门腔静脉内支架分流术(TIPSS)治疗肝硬化门脉高压症30例,29例手术成功,1例失败,7例出现并发症。29例患者术前平均血总胆红紊为25.12±9.80mmol/l,术后为50.46+34.50mmol/l,术前血氨平均为152.33±65.30μg/dl,术后为233.33±99.96μg/dl。作者分析了并发症的成因,认为肝性脑病、黄疸与肝功能状态与分流通道直径大小有关,其他并发症如肝内多发脓肿、肺内感染、菌血症等与伴随疾病和操作技术有关。本文介绍了 TIPSS 术前术后及并发症的治疗原则,讨论了TIPSS 的适应证与禁忌证。     

Nachsorge bei TIPSS Vergleich zwischen Farbdopplersonographie und Portographie

Zusammenfassung Fragestellung: Vergleich zwischen Farbdopplersonographie und Portographie zur Nachsorge von TIPSS-Patienten. Material und Methoden: In einer prospektiven Studie wurde bei 40 konsekutiven TIPSS-Patienten im Rahmen der Nachsorge eine ven?se Portographie und am selben Tag eine Farbdopplersonographie durchgeführt. Innerhalb des TIPSS wurden Flu?werte am Einflu?trakt (portales Segment) und Ausflu?trakt (Lebervenensegment) gemessen. Ergebnisse: Bei 28 Patienten mit unauff?lligem Shunt lag die Flu?geschwindigkeit im Einflu?trakt zwischen 30–120 cm/s (Median 60 cm/s), im Ausflu?trakt zwischen 60–155 cm/s (Median 82 cm/s). Im Ausflu?trakt war die Flu?geschwindigkeit signifikant h?her als im Einflu?trakt (p<0,001). Bei 12 Patienten mit Shuntdysfunktion war die Flu?geschwindigkeit im TIPSS-Einflu?trakt reduziert auf 26±7 cm/s (p<0,0001). Schlu?folgerung: Aufgrund der Beschleunigung der Flu?geschwindigkeit im Ausflu?trakt ist eine getrennte dopplersonographische Beurteilung beider Shuntenden erforderlich. Bei einer Shuntdysfunktion ist die Flu?geschwindigkeit im Einflu?trakt reduziert. Die Farbdopplersonographie ist als nicht invasive Methode zur TIPSS-Nachsorge geeignet.      

Quantification of Changes in Electroencephalographic Power Spectra in a Patient with Budd-Chiari-Syndrome after Implantation of a Transjugular Intrahepatic Portosystemic Stent Shunt (TIPSS)

We examined a 41-year-old female with a subacute Budd-Chiari Syndrome (BCS) before and after implantation of a transjugular intrahepatic portosystemic stent shunt (TIPSS) by means of digital electroencephalography (EEG). After TIPSS implantation hepatic decompression had been achieved and the liver function as well as the clinical status improved daily. Simultaneously, the digital EEG showed a decrease in the power of the theta band and an increase in the physiological alpha frequency band. The theta/alpha ratio decreased after TIPSS, despite an elevated arterial ammonia level. The patient had a well-preserved liver parenchyma before the occurrence of the BCS. After portal decompression by TIPSS, the liver function normalized and the liver resumed efficient synthesis and parts of its detoxification task. This regeneration capacity was documented by a rise in cholinesterase after TIPSS. After temporary substitution of albumin the serum albumin concentration returned to normal. Thus, some neurotoxic substances with high albumin-binding capacity may not be absorbed by the central nervous system (CNS). Furthermore, it appears likely that the length of time the brain is exposed to neurotoxic substances plays a role in the clinical and electroencephalographic changes. Compared to the conventional EEG the theta/alpha ratio reflected better metabolically conditioned electroencephalographic changes after TIPSS.     

门脉高压症经颈内静脉肝内门体分流术前后彩色多普勒超声与X线门静脉造影比较

我院1993年8月至1995年11月对142例门脉高压症患者在经颈内静脉肝内门体分流术（TransjugularIntrahepaticPortosystemicShuntTIPSS）前后行彩色多普勒超声检查，并与门静脉X线造影比较，结果表明彩色多普勒与门静脉造影在TIPSS术前后的运用各具优点，两种方法互补最为有益。     

Efficacy of balloon angioplasty,restenting, and parallel shunt insertion for shunt insufficiency after transjugular intrahepatic portosystemic stent-shunt (TIPSS)

Summary

Our aim was to assess the efficacy of balloon angioplasty, restenting and parallel shunt insertion in maintaining the patency of transjugular intrahepatic portosystemic stent-shunts (TIPSS). From July 1991 to July 1997 TIPSS was successfully performed in 223 patients. Shunt patency was assessed by direct transjugular portography at 4 months, then 6 monthly, or whenever complications occurred. 101 patients developed shunt insufficiency, requiring intervention. 45 patients had their initial shunt restented and 34 of them went on to have further balloon angioplasty of their shunt. 61 patients were managed by balloon angioplasty of the shunt alone and 53 of them still have a patent shunt. 29 patients had a parallel shunt inserted and 16 still have a patent parallel shunt at the end of the follow-up period. Primary shunt patency was 58% in 1 year and 32% over 2 years. Over a total population of 223 patients who underwent TIPSS insertion, in 202 (90.6%) secondary patency is maintained. The combination of balloon angioplasty, restenting and parallel shunt insertion was effective in maintaining shunt patency in the vast majority of patients who underwent TIPSS insertion. Regular shunt surveillance is required.     

饮食护理对经颈静脉肝内门体静脉内支架分流术后患者肝性脑病的预防效果

目的观察饮食护理对经颈静脉肝内门体静脉内支架分流术(transjugular intrahepatic portosystem stent-shunt,TIPSS)术后患者肝性脑病的预防效果。方法选取在福建医科大学附属第一医院接受TIPSS术治疗的90例食管胃底静脉破裂出血患者作为研究对象,依据护理方法的不同将其分为观察组(n=45)和对照组(n=45)。TIPSS术后对照组实施常规护理,观察组在对照组的基础上实施饮食护理,比较两组护理后肝性脑病发生率及护理满意度。结果观察组护理满意度明显高于对照组,肝性脑病发生率明显低于对照组,差异均有统计学意义(P<0.05)。结论在常规护理基础上采用饮食护理,可降低TIPSS术后患者肝性脑病发生率,提高护理满意度的效果优于单纯常规护理。