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限流支架治疗经颈静脉肝内门体分流术后复发性或持续性显性肝性脑病的效果和安全性
Safety and efficacy of flow-reducing stent in treatment of recurrent or persistent hepatic encephalopathy after transjugular intrahepatic portosystemic shunt
文章发布日期:2019年07月05日  来源:  作者:何创业,陈辉,吕勇,等  点击次数:111次  下载次数:5次

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【摘要】:目的分析限流支架治疗经颈静脉肝内门体分流术(TIPS)后复发性或持续性肝性脑病的效果和安全性。方法选取空军军医大学第一附属医院2013年1月-2018年8月TIPS术后明确诊断为持续性或复发性显性肝性脑病的患者11例。限流支架置入前后选用客观量表对肝性脑病患者进行准确评估。限流支架应尽量选择同类型和合适长度的金属覆膜支架,术中术后常规门静脉造影并测门静脉压力梯度。主要观察终点为肝性脑病的变化情况。采用配对t检验分析手术前后各项检测指标的变化。结果 11例患者均成功置入限流支架,限流支架置入后1周内8例患者肝性脑病消失,2例患者降为1级,其中1例患者因肝硬化严重并发肝衰竭,肝性脑病改善不明显。直径4 mm限流支架2例,5 mm 8例,6 mm 1例,限流术后门静脉压力梯度升高[(6.09±0.70) mm Hg vs (15.36±2.94) mm Hg,t=253,P=0.003 8]。限流术后数字编码测试所需的时间较术前有显着下降[(269±80) s vs (464±90) s,t=2.94, P=0.001]。术后1个月患者Alb改善显着(t=1.75,P=0.013)。 4 mm限流支架的2例患者分别在术后6个月和12个月因消化道出血死亡; 5 mm限流支架的8例患者有2例在术后3个月再出血,另1例术后15个月发生大量腹水,1例限流术后生存2年后因黄疸、顽固性腹水并发肝衰竭死亡;6 mm限流支架的1例患者术后25 d并发慢加急性肝衰竭死亡。结论限流支架能够有效改善TIPS术后药物治疗无效的持续性或复发性显性肝性脑病且安全可行,但限流支架直径过小可能会引起支架再狭窄继发门静脉压力升高。
【Abstract】:ObjectiveTo investigate the safety and efficacy of flow-reducing stent in the treatment of recurrent or persistent hepatic encephalopathy (HE) after transjugular intrahepatic portosystemic shunt (TIPS). MethodsA total of 11 patients who were diagnosed with recurrent or persistent HE after TIPS in The First Affiliated Hospital of Air Force Medical University from January 2013 to August 2018 were enrolled. Objective scales were used to evaluate the patients with HE before and after the implantation of flow-reducing stent. Metal covered stents with the same type and an appropriate length were selected as the flow-reducing stents, and conventional portal venography and hepatic venous pressure gradient measurement were performed during and after surgery. The primary endpoint was the change in HE. The paired t-test was used to analyze the changes in related indices after surgery. ResultsAll 11 patients underwent successful implantation of the flow-reducing stent. Within 1 week after implantation, 8 patients had disappearance of HE and 2 had HE reduced to grade 1, among whom 1 had no marked improvement in HE due to severe liver cirrhosis and liver failure. Of all patients, 2 used the 4-mm flow-reducing stent, 8 used the 5-mm flow-reducing stent, and 1 used the 6-mm flow-reducing stent, and there was a significant increase in hepatic venous pressure gradient after surgery [(6.09±0.70) mm Hg vs (15.36±2.94) mm Hg,t=253,P=0.003 8]. There was a significant reduction in the time for digital coding test after surgery [(269±80) s vs (464±90) s,t=2.94, P=0.001]. The patients had a significant improvement in albumin at 1 month after surgery (t=1.75, P=0.013). The 2 patients receiving the 4-mm flow-reducing stent died of gastrointestinal bleeding at 6 and 12 months after surgery, respectively; among the 8 patients receiving the 5-mm flow-reducing stent, 2 experienced rebleeding at 3 months after surgery, 1 experienced massive ascites at 15 months after surgery, and 1 died of jaundice, intractable ascites, and liver failure at 2 years after surgery; the 1 patient receiving the 6-mm flow-reducing stent died of acute-on-chronic liver failure on day 25 after surgery. ConclusionFlow-reducing stent can effectively improve recurrent or persistent HE after TIPS and is safe and feasible; however, a small diameter of stent may lead to increased portal hypertension due to stent restenosis.
【关键字】:肝性脑病; 门体分流术, 经颈静脉肝内; 支架; 治疗学
【Key words】:hepatic encephalopathy; portasystemic shunt, transjugular intrahepatic; stents; therapeutics
【引证本文】:HE CY, CHEN H, LYU Y, et al. Safety and efficacy of flow-reducing stent in treatment of recurrent or persistent hepatic encephalopathy after transjugular intrahepatic portosystemic shunt[J]. J Clin Hepatol, 2019, 35(8): 1719-1722. (in Chinese)
何创业, 陈辉, 吕勇, 等. 限流支架治疗经颈静脉肝内门体分流术后复发性或持续性显性肝性脑病的效果和安全性[J]. 临床肝胆病杂志, 2019, 35(8): 1719-1722.

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