TIPS联合GCVE用于门静脉高压并发上消化道大出血的应用价值

摘要/Abstract

摘要： 目的研究经颈静脉肝内门体分流术(TIPS)联合胃冠状静脉栓塞术(GCVE)治疗门静脉高压并发上消化道大出血的临床价值。方法本院74例门静脉高压上消化道大出血患者作为研究对象,其中37例行TIPS联合GCVE,为观察组。另37例行脾切除+贲门周围血管离断术治疗,为对照组。比较两组术后并发症,比较两组手术前后国际标准化比值(INR)、血清白蛋白、总胆红素(TBIL)、纤维蛋白原(Fib)水平。记录术后血栓情况和1年再出血率。结果两组术后白蛋白、INR、TBIL及Fib水平无显著性差异(P>0.05)。两组术后腹水、术后疼痛、切口感染及肺部感染发生率差异无统计学意义(P>0.05)。两组间术后肝性脑病与术后1年再出血发生率差异显著(P<0.05)。观察组不同肝功能分级患者术后肝性脑病发生率差异有统计学意义(P<0.05)。结论 TIPS联合GCVE与脾切除+贲门周围血管离断术治疗门静脉高压上消化道大出血疗效相近,TIPS联合GCVE术后再出血率更低,但可能增加肝性脑病风险。

关键词: 经颈静脉肝内门体分流术, 胃冠状静脉栓塞术, 门静脉高压, 消化道出血, 临床价值

Abstract: Objective To study the clinical value of transjugular intrahepatic portosystemic shunt (TIPS) and gastric coronary vein embolization (GCVE) in the treatment of portal hypertension with massive upper gastrointestinal hemorrhage. Methods Seventy-four patients with portal hypertension and massive upper gastrointestinal hemorrhage in our hospital were selected as study subjects. There were 37 cases undergoing TIPS and GCVE in the observation group, and 37 cases treated with splenectomy and pericardial devascularization in the control group. The postoperative complications were compared between the 2 groups. The international normalized ratio (INR), serum albumin, total bilirubin (TBIL) and fibrinogen (Fib) levels before and after operation were compared between the 2 groups. The postoperative thrombosis and 1-year rebleeding rate were recorded. Results There were no significant differences in the levels of albumin, INR, TBIL and Fib between the 2 groups(P> 0.05). There were no significant differences in the incidences of postoperative ascites, postoperative pain, incision infection and lung infection between the 2 groups (P> 0.05). There were significant differences in the incidence of postoperative hepatic encephalopathy and 1-year rebleeding rate between the 2 groups (P < 0.05). In the observation group, there was significant difference in the incidence of hepatic encephalopathy among patients with different liver function grades after operation (P<0.05). Conclusion The TIPS combined with GCVE has similar efficacy to splenectomy plus pericardial devascularization in the treatment of portal hypertension with massive upper gastrointestinal hemorrhage. The 1-year rebleeding rate after TIPS combined with GCVE is lower, but the risk of postoperative hepatic encephalopathy is higher.

Key words: Transjugular intrahepatic portosystemic shunt, Gastric coronary vein embolization, Portal hypertension, Gastrointestinal hemorrhage, Clinical value

王宁, 林芳明, 吕明. TIPS联合GCVE用于门静脉高压并发上消化道大出血的应用价值[J]. 肝脏, 2020, 25(9): 952-954.

WANG Ning, LIN Fang-ming, LV Ming. The application value of TIPS combined with GCVE in the treatment of portal hypertension complicated with massive upper gastrointestinal hemorrhage[J]. Chinese Hepatolgy, 2020, 25(9): 952-954.

参考文献

[1] Rassameehiran S, Teerakanok J, Suchartlikitwong S, et al.Utility of the shock index for risk stratification in patients with acute upper gastrointestinal bleeding.South Med J,2017,110:738-743.
[2] 李敏然,徐小元.肝硬化门静脉高压食管胃静脉曲张出血的防治研究.中华肝脏病杂志,2015,23:247-249.
[3] 赵晓飞,林栋栋,李宁等.脾切除联合食管胃底曲张静脉断流术后应用华法林对门静脉血栓的防治作用.实用肝脏病杂志,2019,22:240-243.
[4] Triantafyllou T, Aggarwal P, Gupta E, et al. PTFE covered stent graft versus bare stent in transjugular intrahepatic portosystemic shunt: systematic review and meta-analysis.J Laparoendosc Adv A,2017,28:867-879.
[5] 田忠, 赵海鹰, 杨福全,等.全腹腔镜下脾切除贲门周围血管离断术.中国实用外科杂志,2006,26:453-454.
[6] 王新伟,孙晓.联合脾切除对BCLC分期A期并门静脉高压症肝细胞癌切除术的疗效及预后影响.肝脏,2018,23:332-335.
[7] 张亚东,白国立,朱继军,等.门脉高压症患者行脾切除加贲门周围血管离断术治疗体会.临床普外科电子杂志,2016,4:31-34.
[8] 靳勇.门静脉高压出血经颈静脉肝内门体静脉分流术治疗及评价.内科理论与实践,2015,10:251-255.
[9] Nardelli S, Lattanzi B, Torrisi S, et al. Sarcopenia is risk factor for development of hepatic encephalopathy after transjugular intrahepatic portosystemic shunt placement.Clin Gastroenterol H,2016,15:934-936.
[10] Miraglia R, Gerasia R, Maruzzelli L, et al. Radiation doses to operators performing transjugular intrahepatic portosystemic shunt using a flat-panel detector-based system and ultrasound guidance for portal vein targeting.Eur Radiol, 2016,27:1-4.
[11] Wang L X, Guo L, Guo F, et al. Brain white matter fiber tracts involved in post-transjugular intrahepatic portosystemic shunt hepatic myelopathy.Neuroreport, 2017,28:1164-1169.
[12] Jansen C, M?ller P, Meyer C.et al.Increase in liver stiffness after transjugular intrahepatic portosystemic shunt is associated with inflammation and predicts mortality. Hepatology, 2018, 67:1472-1484.
[13] 王朝阳, 任建庄, 韩新巍,等.经颈静脉肝内门体分流术联合经导管溶栓治疗肝静脉广泛闭塞型巴德-吉亚利综合征并发急性门静脉血栓的临床疗效.中华消化杂志, 2017, 37:661-665.
[14] 温建生,岳琨,吴智群等.肝硬化门静脉高压并发上消化道出血的3种手术方式比较分析.临床肝胆病杂志,2016,32:264-268.
[15] Lv Y, Qi X, He C, et al. Covered TIPS versus endoscopic band ligation plus propranolol for the prevention of variceal rebleeding in cirrhotic patients with portal vein thrombosis: a randomised controlled trial..Gut,2018,67:2156-2168.