经颈静脉肝内门体分流术后分流道失功和肝性脑病发生的危险因素及预防对策  

Risk factors and countermeasures of shunt dysfunction and hepatic encephalopathy after transjugular intrahepatic portosystemic shunt

作　　者：蔡炜[1,2] 诸葛宇征[1] 仇毓东[3] 张峰[1] 李振磊[1] 张明[1] 贺奇彬[1] 张建武[1] 

机构地区：[1]南京大学医学院附属鼓楼医院消化科,210008 [2]苏州大学附属第二医院消化科 [3]南京大学医学院附属鼓楼医院普通外科,210008

出　　处：《中华消化外科杂志》2013年第11期850-854,共5页Chinese Journal of Digestive Surgery

基　　金：南京市医学重点科技发展项目（ZKX09020）、卫生部国家重点建设专科项目

摘　　要：目的探讨经颈静脉肝内门体分流术（TIPS）后发生分流道失功和肝性脑病的危险因素及预防对策。方法回顾性分析2008年8月至2013年1月南京大学医学院附属鼓楼医院收治的116例肝硬化食管胃底静脉曲张破裂出血（EGVB）患者的临床资料。所有患者接受TIPS治疗，其中使用裸支架39例、血管覆膜支架32例和联合支架45例。记录患者的性别、年龄、肝硬化病因、肝功能CTP分级及评分、既往EGVB治疗史、支架类型、门静脉穿刺部位等资料。随访从TIPS手术当日开始，术后第5天行分流道彩色多普勒超声造影检查，术后1、3、6个月及以后每隔6个月均行分流道彩色多普勒超声造影检查。随访时间截至2013年3月。采用COX回归模型单因素分析筛选影响TIPS术后发生分流道失功和肝性脑病的相关变量，再将单因素分析筛选出的变量进行多因素分析。结果TIPS术后5d至36个月18例患者发生分流道失功。发生分流道失功的患者中，采用裸支架者10例，采用血管覆膜支架和联合支架者各4例。65例患者随访时间〉1年，其中59例在术后1年内分流道保持通畅，术后1年通畅率为90．8％（59／65）。12例患者经再次介入溶栓成功，5例未成功，1例因经济原因未处理，再介入通畅率为95．65％（110／115）。29例患者于TIPS术后1～18个月发生肝性脑病，其中5例发生2次以上肝性脑病，3例进展为肝衰竭，1例死亡。21例患者肝性脑病发生在术后3个月内，8例患者肝性脑病发生在术后4～18个月。26例患者肝性脑病为West—HavenⅠ～Ⅱ级，3例患者为West—HavenⅢ级。单因素分析结果表明：肝功能CTP分级、CTP评分、TBil是TIPS术后发生分流道失功的危险因素（RR=0．314，0．600，0．940，P〈0．05）。年龄、肝功能CTP分级、CTP评分是TIPS术后发生肝性脑病的危险因素（RR=2．798，2．683，1．328，P〈0．05）。多因素分Objective To investigate the risk factors of shunt dysfunction and hepatic encephalopathy after transjugular intrahepatie portosystemic shunt （TIPS）, and explore the preventive strategies. Methods The clinical data of 116 patients with esophagus and gastric varices bleeding （EGVB） who were admitted to the Affiliated Drum Tower Hospital of Nanjing University Medical School from August 2008 to January 2013 were retrospectively analyzed. All patients received TIPS, including 39 patients treated with bare stents, 32 with coated stents and45 with combined stents. Gender, age, causes of hepatic cirrhosis, Child-Turcotte-Pugh （CTP） classification and scores, history of EGVB treatment, timing of operation, types of stents, location of puncture in the portal vein were recorded. Follow-up began from the day of TIPS. Patients received color Doppler uhrasonography examination of the shunt at post-TIPS day 5, month 1, 3, 6, and every 6 months thereafter. All the patients were followed up till March 2013. Risk factors influencing the incidence of shunt dysfunction and hepatic encephalopathy were screened out using the COX regression model, and then related factors were processed with multivariate analysis. Results Shunt dysfunction was detected in 18 patients at post-TIPS day 5 to month 36. Of the 18 patients with shunt dysfunction, 10 patients were treated with bare stents, 4 with coated stents and 4 with combined stents. Sixty- five patients were followed up more than 1 year, the shunt remained patency within the 1 year in 59 patients, and the postoperative 1-year stent patency rate was 90.8% （59/65）. The shunt of 12 patients restored patency after interventional therapy, and interventional therapy was failed in 5 patients, 1 patient gave up treatment due to economical reasons. The patency rate after interventional therapy was 95.65% （110/115）. Twenty-nine patients were complicated with hepatic encephalopathy at post-TIPS month 1-18, including 5 patients had the hepatic encephalopathy more than 2 times, 3

关 键 词：门静脉高压症 经颈静脉肝内门体分流术 分流道失功 肝性脑病 

分 类 号：R747.9[医药卫生—神经病学与精神病学]