TIPS术中胆汁漏出：刺激平滑肌细胞增生?

目的经颈内静脉肝内门腔静脉分流术（ＴＩＰＳ）中胆道损伤并胆汁漏出，可能是引起ＴＩＰＳ术后支架内平滑肌细胞（ＳＭＣ）增生和狭窄的重要因素。本研究以离体ＳＭＣ培养和ＴＩＰＳ猪模型实验评价胆汁对ＳＭＣ的作用。材料与方法离体ＳＭＣ培养分为三组：Ⅰ组＝１．０％血清＋１．０％胆汁；Ⅱ组＝１０．０％血清＋１．０％胆汁；Ⅲ组＝１０．０％血清。细胞收获点分别为３、１０、１４天。动物实验组共用４５只猪建立ＴＩＰＳ模型，术后处死时间为１０～１６天。结果此前预试验结果：使用２．５％、５．０％、１０．０％胆汁的培养基，ＳＭＣ在３天内全部死亡。离体细胞培养（１．０％胆汁）实验组（Ⅰ、Ⅱ组）中的脱氧核糖核酸（ＤＮＡ）和总蛋白量明显较对照组（Ⅲ组）少（Ｐ＜０．０５），且随着培养时间的延长其差异增加。动物实验组：２８．８９％的标本证实有胆汁漏出。定量分析示胆汁漏组中的ＳＭＣ增殖量较无胆汁漏组少。组织学检查发现有新生胆管在支架内生长。结论２．５％～１０．０％胆汁杀死ＳＭＣ，１．０％胆汁可抑制ＳＭＣ生长。动物实验示胆汁漏出导致ＳＭＣ增生减少，但血栓形成增加，从而使支架闭塞率增高。

Bile leakage in transjugular intrahepatic portosystemic shunt: effect on SMC proliferation?

Purpose To evaluate the effect of bile on SMC proliferation in vitro and in vivo in a porcine TIPS model. Materials and methods In vitro, SMCs explanted from porcine thoracic aorta were cultured by standard techniques, and were then subcultured in one of three groups: 1% PS(porcine serum) 1% bile; 10% PS. Cells were harvested at 3,10 or 14 days with measurement of DNA, protein and DPM. In vivo, TIPS was successfully performed in 45 swine. The proliferative response within the stent was histologically quantified and correlated to the evidence of bile leak. Results In our pilot studies, a culture medium with 2.5% to 10% bile caused 100% SMC mortality by 3 days. With the concentration of 1% bile, both DNA and protein production decreased significantly in the presence of bile vs. PS alone ( P <0.05). In the in vivo model, 13 of 45 specimens (29%) showed bile leakage by gross or microscopic examination. SMC proliferation was less in animals than in those without bile leak. Thrombus formation was the primary component of TIPS occlusion or stenosis in specimens with bile leak, while myofibroblastic proliferation was the major component in the group without bile leak. Conclusion These data, from both in vitro and in vivo studies, suggest that the proliferative response in TIPS is not primary due to bile leak.