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

doi:10.3969/j.issn.1672-5069.2019.02.019

摘要/Abstract

摘要： 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。

关键词: 肝硬化, 门静脉高压症, 经颈静脉肝内门体分流术, 治疗

Abstract: Objective To investigate the role of transjugular intrahepatic portosystemic shunt（TIPS） in the treatment of cirrhotics with portal hypertension. Methods A retrospective analysis was made on 147 patients with liver cirrhosis and portal hypertension,and all the patients received TIPS between March 2012 and January 2017. The patients received hepatic CT check-up and three-dimensional reconstruction of hepatic vein and portal vein was made. Results All the 147 patients were treated with TIPS by the right jugular vein approach,and 146 cases（99.3%） were successfully operated. Intraoperative punctures in bile duct,gallbladder,hepatic artery and liver capsule were 5 cases （3.4%）,2 cases （1.4%）,4 cases （2.7%） and 8 cases （5.5%）,whereas no abdominal or bile duct bleeding occurred;ectopic embolism occurred in 2 cases （1.4%）;the preoperative dry weight was （13.0±2.1） kg, fasting blood glucose was （6.4±1.0） mmol/L,fasting insulin levels was （20.2±9.3） mU/L,albumin was （37.4±5.0） g/L,creatinine was （59.2±15.9） μmol/L,urea was （5.1±1.6） mmol/L,total bilirubin was （18.6±5.0） μmol/L,blood ammonia was（66.8±24.3） μmol/L,while at the end of 3 months after TIPS,these indexes were （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 and（70.1±34.4） μmol/L,respectively,suggesting postoperative portal venous pressure significantly decreased,dry weight and total bilirubin levels significantly increased; within 12 months of follow-up,there were stent stenosis in 31 cases （21.2%） and hepatic encephalopathy in 25 cases （17.12%）. Conclusion TIPS is a reliable method for treatment of liver cirrhosis with portal hypertension,which might effectively improve the patients' conditions. The key of the operation is the precise puncture,preoperative CT three-dimensional reconstruction of liver and hepatic vein and portal vein,and intraoperative portal vein angiography.

Key words: Cirrhosis, Portal hypertension, Transjugular intrahepatic portosystemic shunt, Therapy

陈俊邦,李健,梁俊迪,全毅,黎广庆,杨开. 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[J]. 实用肝脏病杂志, 2019, 22(2): 228-231.

Chen Junbang, Li Jian, Liang Jundi, Quan Yi, Li Guangqing, Yang Kai. Application of transjugular intrahepatic portosystemic shunt in the treatment of cirrhotics with portal hypertension[J]. JOURNAL OF PRACTICAL HEPATOLOGY, 2019, 22(2): 228-231.

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