经颈静脉肝内门体分流术对脾切除术后门静脉血栓患者食管静脉曲张再出血的预防价值

李赵鹏; 王广川; 张春清

doi:10.3969/j.issn.1001-5256.2021.06.023

经颈静脉肝内门体分流术对脾切除术后门静脉血栓患者食管静脉曲张再出血的预防价值

DOI: 10.3969/j.issn.1001-5256.2021.06.023

1.
青岛市市立医院微创介入治疗科，山东青岛 266011
2.
山东省立医院消化科，济南 250021

利益冲突声明：本研究不存在研究者、伦理委员会成员、受试者监护人以及与公开研究成果有关的利益冲突。

作者贡献声明：李赵鹏负责课题设计，资料分析，参与手术操作，撰写论文；王广川负责手术操作，参与收集数据，修改论文；张春清指导手术操作，拟定写作思路，指导撰写文章并最后定稿。

详细信息

作者简介:
李赵鹏(1981—)，男，主要从事门静脉高压和血管介入的基础和临床研究

通信作者:
张春清，zhchqing@medmail.com.cn

中图分类号: R575.2
计量
- 文章访问数: 569
- HTML全文浏览量: 117
- PDF下载量: 34
- 被引次数: 0
出版历程
- 收稿日期: 2020-10-28
- 录用日期: 2020-12-16
- 出版日期: 2021-06-20

Value of transjugular intrahepatic portosystemic shunt in the prevention of esophageal variceal rebleeding in patients with portal vein thrombosis after splenectomy

1.
Department of Interventional Radiography, Qingdao Municipal Hospital, Qingdao, Shandong 266011, China
2.
Department of Gastroenterology, Shandong Provincial Hospital, Jinan 250021, China

摘要

摘要: 目的探讨预防脾切除术后门静脉血栓(PVT)患者发生食管静脉曲张再出血，行经颈静脉肝内门体分流术(TIPS)的技术成功率和结局。方法回顾性分析2009年12月—2017年1月山东省立医院收治的因预防食管静脉曲张再出血行TIPS的46例脾切除术后PVT患者的临床资料。根据TIPS是否成功, 将患者分为TIPS成功组(38例)和TIPS失败组(8例)，分析两组患者术后曲张静脉再出血、支架功能障碍、肝性脑病(HE)及生存状况。计量资料两组间比较采用配对t检验，计数资料两组间比较采用χ²检验。Kaplan-Meier曲线分析无曲张静脉再出血率、支架通畅率、无HE发生率和生存率。累积无再出血率和累积生存率比较采用log-rank检验。结果 TIPS成功率为82.6%。TIPS成功组与失败组6、12、24个月累积无再出血率分别为94.3%、89.8%、89.8%和85.7%、85.7%、28.6%，两组比较差异有统计学意义(χ²=4.563，P=0.033)。TIPS成功组支架在6、12、24个月累积通畅率分别为79.3%、74.3%、69.0%，TIPS术后累积无HE发生率在6、12、24个月分别为72.1%、55.5%、55.5%。TIPS成功组与失败组6、12、24个月累积生存率分别为94.0%、94.0%、86.2%和71.4%、71.4%、71.4%，两组比较差异有统计学意义(χ²=4.988，P=0.026)。结论 TIPS是预防脾切除术后PVT患者食管静脉曲张再出血的一种安全可行的方法。将TIPS与经皮经肝途径相结合可以促进技术成功。
- 门体分流术，经颈静脉肝内 /
- 门静脉血栓 /
- 脾切除术 /
- 食管和胃静脉曲张
Abstract: Objective To investigate the technical success rate and outcome of transjugular intrahepatic portosystemic shunt (TIPS) in preventing esophageal variceal rebleeding in patients with portal vein thrombosis (PVT) after splenectomy. Methods A retrospective analysis was performed for the clinical data of 46 patients with PVT after splenectomy who were admitted to Shandong Provincial Hospital from December 2009 to January 2017 and underwent TIPS to prevent esophageal variceal rebleeding. According to the success or failure of TIPS, the patients were divided into TIPS success group with 38 patients and TIPS failure group with 8 patients. The two groups were compared in terms of postoperative variceal rebleeding, stent dysfunction, hepatic encephalopathy (HE), and survival. The paired t-test was used for comparison of continuous data between two groups, and the chi-square test was used for comparison of categorical data between two groups. The Kaplan-Meier curve was used to analyze variceal rebleeding-free rate, stent patency rate, HE-free rate, and survival rate, and the log-rank test was used for comparison of cumulative rebleeding-free rate and cumulative survival rate. Results The technical success rate of TIPS was 82.6%. There were significant differences in 6-, 12-, and 24-month cumulative rebleeding-free rates between the TIPS success group and the TIPS failure group (94.3%/89.8%/89.8% vs 85.7%/85.7%/28.6%, χ²=4.563, P=0.033). In the TIPS success group, the 6-, 12-, and 24-month cumulative stent patency rates were 79.3%, 74.3%, and 69.0%, respectively, and the 6-, 12-, and 24-month cumulative HE-free rates after TIPS were 72.1%, 55.5%, and 55.5%, respectively. There were significant differences in 6-, 12-, and 24-month cumulative survival rates between the TIPS success group and the TIPS failure group (94.0%/94.0%/86.2% vs 71.4%/71.4%/71.4%, χ²=4.988, P=0.026). Conclusion TIPS is a safe and feasible method for preventing esophageal variceal rebleeding in patients with PVT after splenectomy, and TIPS combined with a percutaneous transhepatic approach may promote technical success.
- Portosystemic Shunt, Transjugular Intrahepatic /
- Portal Vein Thrombosis /
- Splenectomy /
- Esophageal and Gastric Varices

HTML全文

图 1 TIPS示例图

注：a，术前CT扫描见脾切术后MPV部分阻塞，肝内门静脉分支变细，显示不清；b、c，门静脉造影可见MPV内充盈缺损，MPV周边侧支静脉形成，SMV发出侧支血管参与食管曲张静脉供血；d，对比剂进入腹腔，使用弹簧圈对出血血管栓塞；e，TIPS术后分流道通畅，对比剂外渗消失；f，术后6个月CT门静脉成像示支架通畅。

下载: 全尺寸图片幻灯片

图 2 经颈静脉联合经皮经肝途径完成TIPS

注：a，门静脉造影可见，MPV及SMV近端布满血栓，MPV周围有大量侧枝血管形成；b，曲张静脉栓塞；c，栓塞完毕造影；d，TIPS术后造影。

下载: 全尺寸图片幻灯片

图 3 生存曲线

注：a，TIPS成功组和失败组累积无曲张静脉再出血率；b、c，TIPS成功组累积支架通畅率及累积无HE发生率；d，TIPS成功组和失败组累积生存率。

下载: 全尺寸图片幻灯片

表 1 患者基线特征

指标	数值
年龄(岁)	51.13±10.70
男/女(例)	28/18
TIPS与脾切除术间隔(年)	8.30±5.79
肝炎类型(例)
乙型肝炎	22
丙型肝炎	1
酒精性肝炎	4
其他	19
Child-Pugh分级(A/B/C，例)	16/28/2
总胆红素(μmol/L)	19.23±10.31
血清白蛋白(g/L)	30.73±4.66
血尿素氮(mmol/L)	5.02±2.47
肌酐(μmol/L)	60.20±23.73
血清钠(mmol/L)	136.40±18.94
凝血酶原时间(s)	14.27±1.65
国际标准化比值	1.20±0.14
血红蛋白(g/L)	87.45±20.68
白细胞(×10⁹/L)	6.73±5.74
血小板(×10⁹/L)	252.96±118.58
食管静脉曲张分级(轻度/中度/重度，例)	4/2/40
门静脉海绵样变(有/无，例)	28/18
MPV (条索化/完全阻塞/部分阻塞，例)	10/14/22
RPV (完全阻塞/部分阻塞/通畅，例)	7/29/10
LPV (完全阻塞/部分阻塞/通畅，例)	9/24/13
SMV (完全阻塞/部分阻塞/通畅，例)	8/16/22
注：LPV，门静脉左支；RPV，门静脉右支。

下载: 导出CSV

参考文献(21)

[1]	LUO J, LI M, ZHANG Y, et al. Percutaneous transhepatic intrahepatic portosystemic shunt for variceal bleeding with chronic portal vein occlusion after splenectomy[J]. Eur Radiol, 2018, 28(9): 3661-3668. DOI: 10.1007/s00330-018-5360-z.
[2]	MAKDISSI FF, HERMAN P, MACHADO MA, et al. Portal vein thrombosis after esophagogastric devascularization and splenectomy in schistosomal portal hypertension patients: What's the real importance?[J]. Arq Gastroenterol, 2009, 46(1): 50-56. DOI: 10.1590/s0004-28032009000100014.
[3]	DANNO K, IKEDA M, SEKIMOTO M, et al. Diameter of splenic vein is a risk factor for portal or splenic vein thrombosis after laparoscopic splenectomy[J]. Surgery, 2009, 145(5): 457-464; discussion 465-466. DOI: 10.1016/j.surg.2008.06.030.
[4]	IKEDA M, SEKIMOTO M, TAKIGUCHI S, et al. High incidence of thrombosis of the portal venous system after laparoscopic splenectomy: A prospective study with contrast-enhanced CT scan[J]. Ann Surg, 2005, 241(2): 208-216. DOI: 10.1097/01.sla.0000151794.28392.a6.
[5]	HE S, HE F. Predictive model of portal venous system thrombosis in cirrhotic portal hypertensive patients after splenectomy[J]. Int J Clin Exp Med, 2015, 8(3): 4236-4242.
[6]	DIAO YP, YANG N, GUO LL, et al. Unconventional interventional therapy for cavernous transformation of the portal vein[J]. Ann Vasc Surg, 2014, 28(7): 1791. e9-1791. e11. DOI: 10.1016/j.avsg.2014.03.005.
[7]	SENZOLO M, TIBBALS J, CHOLONGITAS E, et al. Transjugular intrahepatic portosystemic shunt for portal vein thrombosis with and without cavernous transformation[J]. Aliment Pharmacol Ther, 2006, 23(6): 767-775. DOI: 10.1111/j.1365-2036.2006.02820.x.
[8]	LUCA A, MIRAGLIA R, CARUSO S, et al. Short- and long-term effects of the transjugular intrahepatic portosystemic shunt on portal vein thrombosis in patients with cirrhosis[J]. Gut, 2011, 60(6): 846-852. DOI: 10.1136/gut.2010.228023.
[9]	RADOSEVICH PM, RING EJ, LABERGE JM, et al. Transjugular intrahepatic portosystemic shunts in patients with portal vein occlusion[J]. Radiology, 1993, 186(2): 523-527. DOI: 10.1148/radiology.186.2.8421759.
[10]	LUO X, WANG Z, TSAUO J, et al. Advanced cirrhosis combined with portal vein thrombosis: A randomized trial of TIPS versus endoscopic band ligation plus propranolol for the prevention of recurrent esophageal variceal bleeding[J]. Radiology, 2015, 276(1): 286-293. DOI: 10.1148/radiol.15141252.
[11]	FANELLI F, ANGELONI S, SALVATORI FM, et al. Transjugular intrahepatic portosystemic shunt with expanded-polytetrafuoroethylene-covered stents in non-cirrhotic patients with portal cavernoma[J]. Dig Liver Dis, 2011, 43(1): 78-84. DOI: 10.1016/j.dld.2010.06.001.
[12]	QI X, HAN G, YE C, et al. Splenectomy causes 10-fold increased risk of portal venous system thrombosis in liver cirrhosis patients[J]. Med Sci Monit, 2016, 22: 2528-2550. DOI: 10.12659/msm.898866.
[13]	WANG MQ, LIN HY, GUO LP, et al. Acute extensive portal and mesenteric venous thrombosis after splenectomy: Treated by interventional thrombolysis with transjugular approach[J]. World J Gastroenterol, 2009, 15(24): 3038-3045. DOI: 10.3748/wjg.15.3038.
[14]	QI X, BAI M, GUO X, et al. Pharmacologic prophylaxis of portal venous system thrombosis after splenectomy: A meta-analysis[J]. Gastroenterol Res Pract, 2014, 2014: 292689. DOI: 10.1155/2014/292689.
[15]	SONG B, MIN P, OUDKERK M, et al. Cavernous transformation of the portal vein secondary to tumor thrombosis of hepatocellular carcinoma: Spiral CT visualization of the collateral vessels[J]. Abdom Imaging, 2000, 25(4): 385-393. DOI: 10.1007/s002610000057.
[16]	KINJO N, KAWANAKA H, AKAHOSHI T, et al. Risk factors for portal venous thrombosis after splenectomy in patients with cirrhosis and portal hypertension[J]. Br J Surg, 2010, 97(6): 910-916. DOI: 10.1002/bjs.7002.
[17]	LUO X, NIE L, ZHOU B, et al. Transjugular intrahepatic portosystemic shunt for the treatment of portal hypertension in noncirrhotic patients with portal cavernoma[J]. Gastroenterol Res Pract, 2014, 2014: 659726. DOI: 10.1155/2014/659726.
[18]	HAN G, QI X, HE C, et al. Transjugular intrahepatic portosystemic shunt for portal vein thrombosis with symptomatic portal hypertension in liver cirrhosis[J]. J Hepatol, 2011, 54(1): 78-88. DOI: 10.1016/j.jhep.2010.06.029.
[19]	DONG F, LUO SH, ZHENG LJ, et al. Incidence of portal vein thrombosis after splenectomy and its influence on transjugular intrahepatic portosystemic shunt stent patency[J]. World J Clin Cases, 2019, 7(17): 2450-2462. DOI: 10.12998/wjcc.v7.i17.2450.
[20]	WANG L, HE F, YUE Z, et al. Techniques and long-term effects of transjugular intrahepatic portosystemic shunt on liver cirrhosis-related thrombotic total occlusion of main portal vein[J]. Sci Rep, 2017, 7(1): 10868. DOI: 10.1038/s41598-017-11455-y.
[21]	STAMOU KM, TOUTOUZAS KG, KEKIS PB, et al. Prospective study of the incidence and risk factors of postsplenectomy thrombosis of the portal, mesenteric, and splenic veins[J]. Arch Surg, 2006, 141(7): 663-669. DOI: 10.1001/archsurg.141.7.663.