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肝窦阻塞综合征患者行经颈静脉肝内门体分流术后死亡原因分析
Causes of death after transjugular intrahepatic portosystemic shunt in patients with hepatic sinusoidal obstruction syndrome
文章发布日期:2020年11月13日  来源:  作者:凃晶晶,肖江强,张峰,等  点击次数:2896次  下载次数:35次

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【摘要】:目的 分析肝窦阻塞综合征(HSOS)患者行经颈静脉肝内门体分流术(TIPS)后死亡的临床特点及原因,探讨进一步提高此类患者生存率的防治措施。方法 回顾性分析2013年1月-2019年12月南京鼓楼医院收治的HSOS患者293例,其中行TIPS治疗后死亡20例,统计并分析20例患者的一般资料、实验室检查及临床治疗方案,比较病程不同阶段的指标变化及出现并发症等情况。正态分布的计量资料术前术后比较采用配对t检验;非正态分布的计量资料术前术后比较采用Wilcoxon秩和检验。结果 20例死亡患者的平均生存时间为(15.15±4.21)周。其中男15例,女5例,平均年龄(67.60±7.01)岁,≥60岁患者17例(85%),90%以上的患者有腹胀、少尿等临床表现。9例(45%)合并慢性基础疾病,5例(25%)合并两种以上基础疾病。总体上,门静脉压力由术前的(21.67±5.15)mm Hg下降至术后的(8.17±4.98)mm Hg(t=10.318, P<0.05)。患者术前TBil、DBil、D-二聚体水平均明显高于正常值,术后5 d上述指标较术前仍有明显升高(Z值分别为3.823、3.823、2.756,P<0.05);术后5 d Hb、PLT、肌酐水平较术前呈下降趋势(t=4.949、t=2.147、Z=-3.125,P值均<0.05)。3例患者术前即有肝性脑病,术后增至10例(50%)。死亡原因包括急性肝衰竭、感染性休克及多脏器功能衰竭综合征。结论 HSOS患者行TIPS术后死亡的可能危险因素包括合并基础疾病、高胆红素水平及肝性脑病或肾功能不全等并发症。死亡原因主要为急性肝衰竭或多脏器功能衰竭综合征。抗凝过程中需及时复查B超及实验室指标,尽早发现向重型发展的患者,当其指标进行性恶化时,尽早选择TIPS也许可以提高此类患者的生存率,改善预后。此外,术中、术后应重点关注胆道出血,尽早采取措施干预,或可进一步降低病死率。
【Abstract】:Objective To investigate the clinical features and causes of death after transjugular intrahepatic portosystemic shunt (TIPS) in patients with hepatic sinus obstruction syndrome (HSOS), as well as the prevention and treatment measures to further improve the survival rate of such patients. Methods A retrospective analysis was performed for 293 patients with HSOS who were admitted to Nanjing Drum Tower Hospital from January 2013 to December 2019, among whom 20 patients died after TIPS. General information, laboratory examination, and clinical treatment regimen were analyzed, and clinical indices and complications were compared at different stages of the disease. The paired t-test was used for comparison of normally distributed continuous data between groups, and the Wilcoxon rank-sum test was used for comparison of non-normally distributed continuous data between groups. Results The mean survival time was 15.15±4.21 weeks for the 20 patients who died, among whom there were 15 male patients and 5 female patients, with a mean age of 67.60±7.01 years; there were 17 patients (85%) aged ≥60 years, and more than 90% of the patients had abdominal distention and oliguria. Among the 20 patients who died, 9 (45%) had chronic underlying diseases, and 5 (25%) had more than two underlying diseases. Portal venous pressure decreased from 21.67±5.15 mm Hg before surgery to 8.17±4.98 mm Hg after surgery (t=10.318,P<0.05). The levels of total bilirubin, direct bilirubin, and D-dimer were significantly higher than the normal values before surgery, and there were significant increases in these levels on day 5 after surgery (Z=3.823,3.823,2.756, all P<0.05); the hemoglobin level, platelet count, and creatinine level tended to decrease on day 5 after surgery (t=4.979,t=2.147,Z=-3.125, all P<0.05). Three patients had hepatic encephalopathy before surgery, while 10 patients (50%) had hepatic encephalopathy after surgery. Causes of death included acute liver failure, infectious shock, and multiple organ failure syndrome (MODS). Conclusion The possible risk factors for death after TIPS in HSOS patients include underlying diseases, high bilirubin, and complications such as hepatic encephalopathy and renal dysfunction. Causes of death mainly include acute liver failure and MODS. Ultrasound and laboratory markers should be reexamined during anticoagulation therapy to identify the patients with progression to severe diseases as early as possible, and in case of progressive deterioration of indices, TIPS should be selected as early as possible to improve the survival rate and prognosis of such patients. In addition, hemobilia should be observed during and after surgery, and intervention measures should be adopted in time to further reduce mortality rate.
【关键字】:肝静脉闭塞性疾病; 门体分流术,经颈静脉肝内; 死亡原因
【Key words】:hepatic veno-occlusive disease; portasystemic shunt,transjugular intrahepatic; cause of death
【引证本文】:TU JJ, XIAO JQ, ZHANG F, et al. Causes of death after transjugular intrahepatic portosystemic shunt in patients with hepatic sinusoidal obstruction syndrome[J]. J Clin Hepatol, 2020, 36(12): 2751-2755. (in Chinese)
凃晶晶, 肖江强, 张峰, 等. 肝窦阻塞综合征患者行经颈静脉肝内门体分流术后死亡原因分析[J]. 临床肝胆病杂志, 2020, 36(12): 2751-2755.

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