肝硬化患者肝储备功能对TIPSS术后近期疗效的影响
张铁英,赵金满, 施贵静, 中国医科大学附属第一临床医院消化内科 辽宁省沈阳市 110001
项目负责人:赵金满,110001,辽宁省沈阳市和平区北二马路92号,中国医科大学附属第一临床医院消化内科.
电话: 024-23256666-6199
收稿日期: 2004-11-01 接受日期: 2004-11-22
摘要
目的:探讨肝硬化门脉高压上消化道出血患者的肝储备功能对于TIPSS术后近期肝细胞损害和预后的影响.
, 百拇医药 方法:收集肝硬化门脉高压合并上消化道出血经TIPSS术治疗的患者病历资料，采用回顾性的分析方法，对肝功能进行Child-Pugh分级和MELD评分，用c2检验和t检验进行统计学分析.
结果:TIPSS术对肝储备功能不同的肝硬化患者产生不同程度的肝细胞损害.Child-Pugh分级中A，B，C级损害率分别4.76%，30.00%，69.50%，三者之间差异具有显著性(P<0.01).死亡率分别为4.76%，3.30%，13.00%.MELD评分中细胞损害率分别为6.25%，22.20%，90.00%，三者之间差异具有显著性(P<0.01)，死亡率分别为4.20%，3.70%，15.0%.MELD评分中>20肝细胞损害率的95%可信区间为68-99%，而Child-PughC级肝细胞损害率的95%可信区间为47-87%.
结论:TIPSS术对肝硬化患者具有明确的降低门脉压力的疗效，但同时对肝细胞也会产生不同程度的损伤加重;术前正确评价肝储备功能，恰当选择适应证将会减少死亡率.对于TIPSS术预后的判断，MELD评分优于Child-Pugh分级.
, 百拇医药
张铁英, 赵金满, 施贵静. 肝硬化患者肝储备功能对TIPSS术后近期疗效的影响. 世界华人消化杂志 2005;13(3):415-418
Rossle M, Richter GM, Noldge G, Palmaz JC, Wenz W, Gerok W. New non-operative treatment for variceal
haemorrhage. Lancet 1989;2:153
2 Richter GM, Palmaz JC, Noldge G, Rossle M, Siegerstetter V, Franke M, Wenz W. The transjugular
intrahepatic portosystemic stent-shunt. A new nonsurgical percutaneous method. Radiologe 1989;29:406-411
, 百拇医药
3 Hassoun Z, Pomier-Layrargues G. The transjugular intrahepatic portosystemic shunt in the treatment of
portal hypertension. Eur J Gastroenterol Hepatol 2004;16:1-4
4 Narahara Y, Kanazawa H, Kawamata H, Tada N, Saitoh H, Matsuzaka S, Osada Y, Mamiya Y, Nakatsuka K,Yoshimoto H, Koizumi N, Sakamoto C, Kobayashi M. A randomized clinical trial comparing transjugular
intrahepatic portosystemic shunt with endoscopic sclerotherapy in the long-term management of patient with
, 百拇医药
cirrhosis after recent variceal hemorrhage. Hepatol Res 2001;21:189-198
5 Pomier-Layrargue G, Villeneuve JP, Deschenes M, Bui B, Perreault P, Fenyves D, Willems B. Transjugular
intrahepatic portosystemic shunt(TIPS)versus endoscopi variceal ligation in the prevention of variceal rebleeding in
patients with cirrhosis:a randomised trial. Gut 2001;48:390-396
, 百拇医药 6 Tripathi D, Helmy A, Maebeth K, Balata S, Lui HF, Stanley AJ, Redhead DN, Hayes PC. Ten years follow-up of 472
patients following transjugular intrahepatic portosystemic stent-shunt insertion at a single centre.
Eur J Gastroenterol Hepatol 2004;16:9-18
7 Ryan BM, Stockbrugger RW, Ryan JM. A pathophysiologic, gastroenterologic, and radiologic approach to the
, http://www.100md.com management of gastric varices. Gastroenterology 2004;126:1175-1189
8 Tripathi D, Liu HF, Helmy A, Dabos K, Forrest F, Stanley AJ, Jalan R, Redhead DN, Hayes PC. Randomised controlled trial
of long term portographic follow up versus variceal band ligation following transjugular intrahepatic portosystemic
stent shunt for preventing oesophageal variceal rebleeding. Gut 2004;53:431-437
, 百拇医药
9 Zhuang ZW, Teng GJ, Jeffery RF, Gemery JM, Janned抩thee B, Bettmann MA. Long-term results and quality of life
in patients treated with transjugularintrahepatic portosystemic shunts. Am J Roentgenol 2002;179:1597-603
10 Gulberg V, Schepke M, Geigenberger G, Holl J, Brensing KA,Waggershauser T, Reiser M, Schild HH,Sauerbnuch T, Gerbes AL. Transjugularintrahepatic portosystemic shunting is not superior to endoscopic variceal
, 百拇医药
band ligation for prevention ofvariceal rebleeding in cirrhotic patients:a randomized, controlledtrial.
Scand J Gastroenterol 2002;37:338-343
11 Angermayr B, Cejna M, Karnel F, Gschwantler M, Koenig F, Pidlich J,Mendel H, Pichlor L, Wichlas M, Kreil A,Schmid M, Ferlitsch A, Lipinski E,Brunner H, Lammer J, Ferenci P, Gangl A, Peck-Redvsavljevic M. Child-pugh
versus MELD score in predictingsurvival in patients undergoing transjugular intrahepatic portosystemicshunt.
, http://www.100md.com
Gut 2003;52:879-885
12 Malinehoc M, Kamath PS, Gordon FD, Peine CJ, Rank J, ter-Borg PC. Amodel to predict poor survival in
patients undergoingransjugularintrahepatic portosystemic shunt. Hepatology 2000;31:864-871
13 Kamath PS, Wiesner RH, Malinchoc M, Kremers W, Therneau TM, KosbergCL, D扐mico G, Dickson ER, Kim WR.
A model to predict survival inpatient with end-stage liver disease. Hepatology 2001;33:464-470
, 百拇医药
14 Schepke M, Roth F, Fimmers R, Brensing KA, Sudhop T, Schid HH,Sauerbruch T. Comparison of MELD, Child-pugh,and Emory Model for the prediction ofsurvival in patients undergoing transjugular intrahepatic portosystemic
shunting. Am J Gastroenterol 2003;98:1167-1174
15 王宝恩,张定凤. 现代肝脏病学.北京, 科学出版社, 2003:216-217
16 Rosemurgy AS, Thometz DP, Zervos EE. Portal blood flow, effectivehepatic blood flow, and outcome after partial
, http://www.100md.com
portal decompression. J Surg Res 2004;117:64-70
17 Mullen KD. Interplay of portal pressure, portal perfusion andhepatic arterial inflow in modulating expression of
hepatic encephalopathy in patientswith spontaneous or artificially created portosystemic shunts.
Indian J Gastroenterol 2003;22(Suppl 2):S25-27
18 Matsumoto A, Matsushita M, Sugno Y, Takimoto K, Yasuda M, InokuchiH. Limitations of transjugular
, 百拇医药
intrahepatic portosystemic shunt formanagement of gastric varices. Gastroenterology 2004;126:380-381
19 Matsumoto A, Yamauchi H, Inokuchi H. How should we improve theclinical course of patients with gastric varices?
J Clin Gastroenterol 2003;36:372
20 Olde Damink SW, Jalan R, Redhead DN, Hayes PC, Deutz NE, Soeter PB.Interorgan ammonia and amino acid
metabolism in metabolically stablepatients with cirrhosis and a TIPSS. Hepatology 2002;36:1163-1171
, http://www.100md.com
21 ter-Borg PC, Hollemans M, Van Buuren HR, Vleggaar FP, Groeneueg M,Hop WC, Lameris JS. Transjugular
intrahepatic portosystemicshunts:long-term patency and clinical results in a patient cohort observedfor
3-9 years. Radiology 2004;231:537-545
22 Saxon RR. A new era for transjugular intrahepatic portosystemicshunts? J Vasc Interv Radiol 2004;15:217-219
, 百拇医药 23 Ferral H, Gamboa P, Postoak DW, Albermaz VS, Young CR, Speeg KV,McMahan CA. Survival after elective
transjugular intrahepaticportosystemic shunt creation:prediction with model for end-stage liverdisease score.
Radiology 2004;231:231-236
24 Schwartz JM, Beymer C, Althaus SJ, Larson AM, Zaman A, GlickermanDJ, Kowdley KV. Cardiopulmonary consequences
of transjugular intrahepaticportosystemic shunts:role of increased pulmonary artery pressure.
, http://www.100md.com
J Clin Gastroenterol 2004;38:590-594
25 毕向军, 杨冬华,农玉新, 黄纯炽,徐明符, 肖玉梅.经颈静脉肝内门体分流术对肝功能的影响.
世界华人消化杂志 2000;8:594-595
26 Chalasani N, Clark WS, Martin LG, Kamean J, Khan MA, Patel NH,Boyer TD. Determinant of mortality in patient
with advanced cirrhosis aftertransjugular intrahepatic portosystemic shunting. Gastroenterology 2000;118:138-144
, 百拇医药
27 邓侠兴, 杨卫平,蔡伟耀, 陈皓, 李宏为.经颈内静脉肝内门体支架分流门脉血液动力学变化.世界华人消化杂志
1999;7:799-800
28 蒋明德, 秦建平.TIPS的临床应用再评价. 世界华人消化杂志 2003;11:1989-1992
29 Gow PJ, Chapman RW. Modern management of oesophageal varices. PostgradMed J 2001;29:406-411
编辑 张海宁, http://www.100md.com( 张铁英,赵金满, 施贵静)
项目负责人:赵金满,110001,辽宁省沈阳市和平区北二马路92号,中国医科大学附属第一临床医院消化内科.
电话: 024-23256666-6199
收稿日期: 2004-11-01 接受日期: 2004-11-22
摘要
目的:探讨肝硬化门脉高压上消化道出血患者的肝储备功能对于TIPSS术后近期肝细胞损害和预后的影响.
, 百拇医药 方法:收集肝硬化门脉高压合并上消化道出血经TIPSS术治疗的患者病历资料，采用回顾性的分析方法，对肝功能进行Child-Pugh分级和MELD评分，用c2检验和t检验进行统计学分析.
结果:TIPSS术对肝储备功能不同的肝硬化患者产生不同程度的肝细胞损害.Child-Pugh分级中A，B，C级损害率分别4.76%，30.00%，69.50%，三者之间差异具有显著性(P<0.01).死亡率分别为4.76%，3.30%，13.00%.MELD评分中细胞损害率分别为6.25%，22.20%，90.00%，三者之间差异具有显著性(P<0.01)，死亡率分别为4.20%，3.70%，15.0%.MELD评分中>20肝细胞损害率的95%可信区间为68-99%，而Child-PughC级肝细胞损害率的95%可信区间为47-87%.
结论:TIPSS术对肝硬化患者具有明确的降低门脉压力的疗效，但同时对肝细胞也会产生不同程度的损伤加重;术前正确评价肝储备功能，恰当选择适应证将会减少死亡率.对于TIPSS术预后的判断，MELD评分优于Child-Pugh分级.
, 百拇医药
张铁英, 赵金满, 施贵静. 肝硬化患者肝储备功能对TIPSS术后近期疗效的影响. 世界华人消化杂志 2005;13(3):415-418
Rossle M, Richter GM, Noldge G, Palmaz JC, Wenz W, Gerok W. New non-operative treatment for variceal
haemorrhage. Lancet 1989;2:153
2 Richter GM, Palmaz JC, Noldge G, Rossle M, Siegerstetter V, Franke M, Wenz W. The transjugular
intrahepatic portosystemic stent-shunt. A new nonsurgical percutaneous method. Radiologe 1989;29:406-411
, 百拇医药
3 Hassoun Z, Pomier-Layrargues G. The transjugular intrahepatic portosystemic shunt in the treatment of
portal hypertension. Eur J Gastroenterol Hepatol 2004;16:1-4
4 Narahara Y, Kanazawa H, Kawamata H, Tada N, Saitoh H, Matsuzaka S, Osada Y, Mamiya Y, Nakatsuka K,Yoshimoto H, Koizumi N, Sakamoto C, Kobayashi M. A randomized clinical trial comparing transjugular
intrahepatic portosystemic shunt with endoscopic sclerotherapy in the long-term management of patient with
, 百拇医药
cirrhosis after recent variceal hemorrhage. Hepatol Res 2001;21:189-198
5 Pomier-Layrargue G, Villeneuve JP, Deschenes M, Bui B, Perreault P, Fenyves D, Willems B. Transjugular
intrahepatic portosystemic shunt(TIPS)versus endoscopi variceal ligation in the prevention of variceal rebleeding in
patients with cirrhosis:a randomised trial. Gut 2001;48:390-396
, 百拇医药 6 Tripathi D, Helmy A, Maebeth K, Balata S, Lui HF, Stanley AJ, Redhead DN, Hayes PC. Ten years follow-up of 472
patients following transjugular intrahepatic portosystemic stent-shunt insertion at a single centre.
Eur J Gastroenterol Hepatol 2004;16:9-18
7 Ryan BM, Stockbrugger RW, Ryan JM. A pathophysiologic, gastroenterologic, and radiologic approach to the
, http://www.100md.com management of gastric varices. Gastroenterology 2004;126:1175-1189
8 Tripathi D, Liu HF, Helmy A, Dabos K, Forrest F, Stanley AJ, Jalan R, Redhead DN, Hayes PC. Randomised controlled trial
of long term portographic follow up versus variceal band ligation following transjugular intrahepatic portosystemic
stent shunt for preventing oesophageal variceal rebleeding. Gut 2004;53:431-437
, 百拇医药
9 Zhuang ZW, Teng GJ, Jeffery RF, Gemery JM, Janned抩thee B, Bettmann MA. Long-term results and quality of life
in patients treated with transjugularintrahepatic portosystemic shunts. Am J Roentgenol 2002;179:1597-603
10 Gulberg V, Schepke M, Geigenberger G, Holl J, Brensing KA,Waggershauser T, Reiser M, Schild HH,Sauerbnuch T, Gerbes AL. Transjugularintrahepatic portosystemic shunting is not superior to endoscopic variceal
, 百拇医药
band ligation for prevention ofvariceal rebleeding in cirrhotic patients:a randomized, controlledtrial.
Scand J Gastroenterol 2002;37:338-343
11 Angermayr B, Cejna M, Karnel F, Gschwantler M, Koenig F, Pidlich J,Mendel H, Pichlor L, Wichlas M, Kreil A,Schmid M, Ferlitsch A, Lipinski E,Brunner H, Lammer J, Ferenci P, Gangl A, Peck-Redvsavljevic M. Child-pugh
versus MELD score in predictingsurvival in patients undergoing transjugular intrahepatic portosystemicshunt.
, http://www.100md.com
Gut 2003;52:879-885
12 Malinehoc M, Kamath PS, Gordon FD, Peine CJ, Rank J, ter-Borg PC. Amodel to predict poor survival in
patients undergoingransjugularintrahepatic portosystemic shunt. Hepatology 2000;31:864-871
13 Kamath PS, Wiesner RH, Malinchoc M, Kremers W, Therneau TM, KosbergCL, D扐mico G, Dickson ER, Kim WR.
A model to predict survival inpatient with end-stage liver disease. Hepatology 2001;33:464-470
, 百拇医药
14 Schepke M, Roth F, Fimmers R, Brensing KA, Sudhop T, Schid HH,Sauerbruch T. Comparison of MELD, Child-pugh,and Emory Model for the prediction ofsurvival in patients undergoing transjugular intrahepatic portosystemic
shunting. Am J Gastroenterol 2003;98:1167-1174
15 王宝恩,张定凤. 现代肝脏病学.北京, 科学出版社, 2003:216-217
16 Rosemurgy AS, Thometz DP, Zervos EE. Portal blood flow, effectivehepatic blood flow, and outcome after partial
, http://www.100md.com
portal decompression. J Surg Res 2004;117:64-70
17 Mullen KD. Interplay of portal pressure, portal perfusion andhepatic arterial inflow in modulating expression of
hepatic encephalopathy in patientswith spontaneous or artificially created portosystemic shunts.
Indian J Gastroenterol 2003;22(Suppl 2):S25-27
18 Matsumoto A, Matsushita M, Sugno Y, Takimoto K, Yasuda M, InokuchiH. Limitations of transjugular
, 百拇医药
intrahepatic portosystemic shunt formanagement of gastric varices. Gastroenterology 2004;126:380-381
19 Matsumoto A, Yamauchi H, Inokuchi H. How should we improve theclinical course of patients with gastric varices?
J Clin Gastroenterol 2003;36:372
20 Olde Damink SW, Jalan R, Redhead DN, Hayes PC, Deutz NE, Soeter PB.Interorgan ammonia and amino acid
metabolism in metabolically stablepatients with cirrhosis and a TIPSS. Hepatology 2002;36:1163-1171
, http://www.100md.com
21 ter-Borg PC, Hollemans M, Van Buuren HR, Vleggaar FP, Groeneueg M,Hop WC, Lameris JS. Transjugular
intrahepatic portosystemicshunts:long-term patency and clinical results in a patient cohort observedfor
3-9 years. Radiology 2004;231:537-545
22 Saxon RR. A new era for transjugular intrahepatic portosystemicshunts? J Vasc Interv Radiol 2004;15:217-219
, 百拇医药 23 Ferral H, Gamboa P, Postoak DW, Albermaz VS, Young CR, Speeg KV,McMahan CA. Survival after elective
transjugular intrahepaticportosystemic shunt creation:prediction with model for end-stage liverdisease score.
Radiology 2004;231:231-236
24 Schwartz JM, Beymer C, Althaus SJ, Larson AM, Zaman A, GlickermanDJ, Kowdley KV. Cardiopulmonary consequences
of transjugular intrahepaticportosystemic shunts:role of increased pulmonary artery pressure.
, http://www.100md.com
J Clin Gastroenterol 2004;38:590-594
25 毕向军, 杨冬华,农玉新, 黄纯炽,徐明符, 肖玉梅.经颈静脉肝内门体分流术对肝功能的影响.
世界华人消化杂志 2000;8:594-595
26 Chalasani N, Clark WS, Martin LG, Kamean J, Khan MA, Patel NH,Boyer TD. Determinant of mortality in patient
with advanced cirrhosis aftertransjugular intrahepatic portosystemic shunting. Gastroenterology 2000;118:138-144
, 百拇医药
27 邓侠兴, 杨卫平,蔡伟耀, 陈皓, 李宏为.经颈内静脉肝内门体支架分流门脉血液动力学变化.世界华人消化杂志
1999;7:799-800
28 蒋明德, 秦建平.TIPS的临床应用再评价. 世界华人消化杂志 2003;11:1989-1992
29 Gow PJ, Chapman RW. Modern management of oesophageal varices. PostgradMed J 2001;29:406-411
编辑 张海宁, http://www.100md.com( 张铁英,赵金满, 施贵静)
