经颈静脉肝内门体分流术治疗肝硬化食管胃静脉曲张出血伴肌肉减少症患者远期预后分析  

Analysis of the long-term prognosis of transjugular intrahepatic portosystemic shunt treatment for esophagogastric variceal hemorrhage concomitant with sarcopenia in cirrhotic patients

作　　者：王曦旋 张明[1] 尹晓春 高波[3] 顾丽红 李炜 肖江强[1] 张松[1] 张玮[1] 张鑫[4] 邹晓平[1] 王雷[1] 诸葛宇征[1] 张峰[1] Wang Xixuan;Zhang Ming;Yin Xiaochun;Gao Bo;Gu Lihong;Li Wei;Xiao Jiangqiang;Zhang Song;Zhang Wei;Zhang Xin;Zou Xiaoping;Wang Lei;Zhuge Yuzheng;Zhang Feng(Department of Gastroenterology,Affiliated Drum Tower Hospital of Nanjing University Medical School,Nanjing 210000,China;Second Clinical Medical School,Medical School,Southeast University,Nanjing 210000,China;Department of Clinical Nutrition,Affiliated Drum Tower Hospital of Nanjing University Medical School,Nanjing 210000,China;Department of Radiology,Afiliated Drum Tower Hospital of Nanjing University Medical School,Nanjing 210000,China)

机构地区：[1]南京大学医学院附属鼓楼医院消化内科,南京210000 [2]东南大学医学院第二临床医学院,南京210000 [3]南京大学医学院附属鼓楼医院临床营养科,南京210000 [4]南京大学医学院附属鼓楼医院医学影像科,南京210000

出　　处：《中华肝脏病杂志》2024年第8期744-752,共9页Chinese Journal of Hepatology

基　　金：国家自然科学基金(81900552);南京市卫生科学技术发展专项基金重点项目(ZKX19015);南京市卫生科技发展专项资金优秀青年基金项目(JQX20005);南京大学医学院附属鼓楼医院临床试验项目(2022-LCYJ-MS-13)。

摘　　要：目的探讨经颈静脉肝内门体分流术(TIPS)是否能改善肝硬化食管胃静脉曲张破裂出血(EGVB)合并肌肉减少症患者的预后。方法采用回顾性队列研究,选择2017年1月至2019年12月接受标准治疗或TIPS治疗的肝硬化EGVB患者,共464例。治疗后长期进行规律随访。主要结局是无移植生存期;次要终点为再出血、显性肝性脑病(OHE)。对所得数据进行统计学分析。连续变量资料组间比较使用t检验、Wilcoxon秩和检验,分类变量组间比较使用χ^(2)检验或Fisher确切概率法检验。结果纳入研究患者的年龄(55.27±13.86)岁,男性286例。203例患者合并肌肉减少症,261例患者为非合并肌肉减少症。中位随访时间为43个月;2组患者随访时间差异无统计学意义。整体队列中,TIPS组与标准治疗组患者的无移植生存期差异无统计学意义(HR=1.31,95%CI:0.97~1.78,P=0.08)。对于合并肌肉减少症的肝硬化患者,TIPS组无移植生存期较长(中位生存期:47.76个月与52.45个月,χ^(2)=4.09;HR=1.55,95CI:1.01~2.38,P=0.04)。对于非合并肌肉减少症的患者,2种治疗患者的无移植生存期差异无统计学意义(HR=1.22,95%CI:0.78~1.88,P=0.39)。无论是否合并肌肉减少症,TIPS均可延长患者的无再出血时间(非合并肌肉减少症患者:中位再出血时间分别为39.48个月与53.61个月,χ^(2)=18.68;HR=2.47,95CI:1.67~3.65,P<0.01;肌肉减少症患者:中位再出血时间分别为39.91个月与50.68个月,χ^(2)=12.36;HR=2.20,95CI:1.42~3.40,P<0.01)。相较标准治疗组,TIPS增加患者的1年OHE发生率(肌肉减少症患者:6.93%与16.67%,χ^(2)=3.87,P=0.049;非合并肌肉减少症患者:2.19%与9.68%,χ^(2)=8.85,P=0.01);2种治疗组之间长期OHE发生率的差异无统计学意义(P值均>0.05)。结论在合并肌肉减少症的肝硬化伴EGVB患者的二级预防中,相较标准治疗,TIPS可明显延长患者的无移植生存期;而在非合并肌肉减少症的肝硬化EGVB患者中其优势并不突出�Objective To explore whether transjugular intrahepatic portosystemic shunt(TIPS)can improve the prognosis of esophagogastric variceal bleeding(EGVB)combined with sarcopenia in cirrhotic patients.Methods A retrospective cohort study was performed.A total of 464 cases with cirrhotic EGVB who received standard or TIPS treatment between January 2017 and December 2019 were selected.Regular follow-up was performed for the long-term after treatment.The primary outcome was transplantation-free survival.The secondary endpoints were rebleeding and overt hepatic encephalopathy(OHE).The obtained data were statistically analyzed.The t-test and Wilcoxon rank-sum test were used to compare continuous variables between groups.Theχ^(2)test,or Fisher's exact probability test,was used to compare categorical variables between groups.Results The age of the included patients was 55.27±13.86 years,and 286 cases were male.There were 203 cases of combined sarcopenia and 261 cases of non-combined sarcopenia.The median follow-up period was 43 months.The two groups had no statistically significant difference in follow-up time.There was no statistically significant difference in transplant-free survival between the TIPS group and the standard treatment group in the overall cohort(HR=1.31,95%CI:0.97-1.78,P=0.08).The TIPS patient group with cirrhosis combined with sarcopenia had longer transplant-free survival(median survival:47.76 vs.52.45,χ^(2)=4.09;HR=1.55,95CI:1.01~2.38,P-0.04).There was no statistically significant difference in transplant-free survival between the two kinds of treatments for patients without sarcopenia(HR=1.22,95%CI:0.78~1.88,P=0.39).Rebleeding time was prolonged in TIPS patients with or without sarcopenia combination(patients without combined sarcopenia:median rebleeding time:39.48 vs.53.61,χ^(2)=18.68;R=2.47,95CI:1.67~3.65,P<0.01;patients with sarcopenia:median rebleeding time:39.91 vs.50.68,χ^(2)=12.36;HR=2.20,95CI:1.42~3.40,P<0.01).TIPS patients had an increased 1-year OHE incidence rate compared to the standard

关 键 词：肝硬化 食管胃静脉曲张出血 肌肉减少症 经颈静脉肝内门体分流术 治疗 

分 类 号：R575.2[医药卫生—消化系统]