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早期经颈静脉肝内门体分流术临床应用及研究进展
DOI: 10.3969/j.issn.1001-5256.2023.07.001
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作者贡献声明：王泽负责查阅文献和撰写文章；黄金涛、钟斌演、沈健参与修改文章；朱晓黎负责拟定写作思路，指导撰写文章并最后定稿。
Clinical application of early transjugular intrahepatic portosystemic shunt and related and research advances
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摘要: 经颈静脉肝内门体分流术(TIPS)是经颈静脉途径在肝静脉与门静脉之间穿刺建立门体分流通道以此来降低门静脉压力，从而控制急性食管胃静脉曲张出血(EGVB)。EGVB的预后在过去几十年有了显著的改善，目前内镜下套扎联合药物治疗被推荐为一线治疗方案。过去十年EGVB管理的最新进展和研究聚焦在相对较新的“early”或“pre-emptive”TIPS概念，即在标准治疗失败风险较高的EGVB患者中，推荐早期TIPS(入院72 h内，理想情况下24 h内)治疗。本文简要介绍早期TIPS对控制出血、病死率以及肝性脑病的影响，早期TIPS适用的高危人群、干预的时机及成本效益，早期TIPS在真实世界中的应用以及国际指南和共识对早期TIPS的推荐。
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关键词:
- 门体分流术, 经颈静脉肝内 /
- 食管和胃静脉曲张 /
- 出血
Abstract: Transjugular intrahepatic portosystemic shunt (TIPS) is a procedure to establish a portosystemic shunt between the hepatic vein and the portal vein via the jugular approach, so as to reduce portal venous pressure and control acute esophagogastric variceal bleeding (EGVB). The prognosis of EGVB has been improved significantly over the past few decades, and endoscopic variceal ligation combined with drug therapy is now recommended as the first-line treatment regimen for this disease. The latest research advances in the management of EGVB over the past decade have focused on the relatively new concept of "early" or "pre-emptive" TIPS, that is to say, early TIPS (within 72 hours after admission, ideally within 24 hours) is recommended for patients with EGVB who are at a relatively high risk of failure in standard treatment. This article briefly introduces the effect of early TIPS on controlling bleeding, mortality rate, and hepatic encephalopathy, the high-risk population for early TIPS, timing of intervention, cost effectiveness, the applications of early TIPS in a real-world setting, and recommendations for early TIPS in international guidelines and consensus statements. -
表 1 当前国际指南和共识中关于早期TIPS的总结
Table 1. Summary of current international guidelines and consensus on early TIPS
指南 年份 早期TIPS的推荐 高风险人群的定义 Baveno Ⅶ共识[3] 2022 对于在初始药物治疗和内镜治疗后治疗失败风险较高的静脉曲张出血患者，必须考虑在72 h内(最好＜24 h)使用PTFE覆膜支架进行早期TIPS Child-Pugh C级(＜14分) 或Child-Pugh B级伴活动性出血 美国肝病学会[5] 2017 在无禁忌证的失败或再出血高风险患者中，72 h内的早期TIPS可能使选择患者获益 Child-Pugh C级或Child-Pugh B级伴活动性出血 欧洲肝病学会[4] 2018 对于选定的高风险患者建议采用早期TIPS(24~72 h内)。但是高危患者的标准尤其是伴有活动性出血的Child-Pugh B级患者仍然存在争议，需要进一步的研究 Child-Pugh C级(＜14分) 英国胃肠病学会[40] 2020 如果当地资源允许，在血液动力学稳定的高危患者中可以考虑早期TIPS(72 h内)；有必要进行大型多中心随机对照实验以确定Child-Pugh B级伴活动性出血或MELD 12~18分患者是否可以从早期TIPS中获益 Child-Pugh C级(＜14分) 或MELD≥19分 中国医师协会介入医师分会[28] 2019 对于急性EGVB患者，在初次药物联合内镜治疗后，若存在治疗失败的高危因素，应在72 h内(最好在24 h内)行覆膜支架TIPS治疗。对于GOV1、GOV2及IGV胃静脉曲张出血的高危患者应在72 h内(最好在24 h内)行覆膜支架TIPS治疗 Child-Pugh C级(≤13分)或Child-Pugh B级伴内镜证实活动性出血 注：GOV，食管-胃底静脉曲张；IGV，孤立性胃静脉曲张。 
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