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经颈静脉肝内门体分流术联合组织胶栓塞术治疗肝硬化食管胃静脉曲张再出血的效果分析
Clinical effect of transjugular intrahepatic portosystemic shunt combined with tissue adhesive embolization in treatment of gastroesophageal variceal rebleeding in cirrhotic patients
文章发布日期:2018年06月11日  来源:  作者:陈敏, 张峰, 张明, 等  点击次数:230次  下载次数:40次

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【摘要】:目的探讨经颈静脉肝内门体分流术(TIPS)和TIPS联合食管胃曲张静脉组织胶栓塞术(SEVE)治疗肝硬化食管胃静脉曲张再出血(GOVB)的临床疗效。方法收集2009年1月-2013年12月于南京鼓楼医院消化科行TIPS或TIPS+SEVE治疗的肝硬化GOVB患者共142例,分为TIPS组(n=31)和TIPS+SEVE组(n=111)。观察2组术中情况、随访结果并分析影响肝硬化GOVB患者术后再出血的危险因素等。计量资料组间比较采用独立样本t检验,计数资料比较采用χ2检验,等级资料比较采用Mann-Whitney U检验,采用Kaplan-Meier绘制再出血率、分流道失功率和生存率曲线,采用log-rank比较累积再出血率、分流道失功率和生存率,采用Cox回归模型行单因素和多因素分析。结果142例患者均成功完成手术。TIPS组和TIPS+SEVE组患者随访时间[(34±23)个月vs (32±21)个月,t=0.501,P>0.05]、术后肝性脑病发生率(12.9% vs 18.9%,χ2=0.641,P>0.05)比较差异均无统计学意义。TIPS组和TIPS+SEVE组患者随访期间1、2、3、5年累积再出血率比较差异无统计学意义(χ2=1.511,P>0.05)。TIPS组和TIPS+SEVE组患者随访期间1、2、3、5年累积分流道失功发生率分别为13%、21%、34%、34%和7%、12%、13%、13%,2组比较差异有统计学意义(χ2=4.087,P<0.05)。TIPS组和TIPS+SEVE组随访期间患者1、2、3、5年累积生存率比较差异无统计学意义(χ2=0.471,P>0.05)。患者的术前肝功能Child-Pugh分级[风险比(HR)=0.385,95%可信区间(95%CI):0.165~0898]、支架类型(HR=0.429,95%CI:0.240~0.766)和术后分流道失功(HR=5.840,95%CI:2.566~13.294)是影响肝硬化GOVB患者术后再出血的相关因素(P值均<0.05)。多因素分析结果显示:支架类型为裸支架(相对危险度为0.527,95%CI:0290~0.954)和术后发生分流道失功(相对危险度为4.436,95%CI:1.899~10.360)是影响肝硬化GOVB患者术后再出血的独立危险因素(P值均<0.05)。结论TIPS+SEVE与TIPS比较可降低肝硬化GOVB的术后分流道失功发生率,但并不能降低术后再出血率及提高生存率;而术中采用裸支架、分流道失功是影响肝硬化GOVB患者术后再出血的独立危险因素。
【Abstract】:ObjectiveTo investigate the clinical effect of transjugular intrahepatic portosystemic shunt (TIPS) alone versus TIPS combined with stomach and esophageal variceal embolization (SEVE) in the treatment of gastroesophageal variceal rebleeding in cirrhotic patients. MethodsA total of 142 cirrhotic patients with gastroesophageal variceal bleeding who underwent TIPS or TIPS+SEVE in Department of Gastroenterology, Drum Tower Hospital, from January 2009 to December 2013 were enrolled and divided into TIPS group with 31 patients and TIPS+SEVE group with 111 patients. The two groups were analyzed in terms of intraoperative conditions, follow-up results, and risk factors for postoperative rebleeding. The independent samples t-test was used for comparison of continuous data between groups, the chi-square test was used for comparison of categorical data between groups, and the Mann-Whitney U test was used for comparison of ranked data between groups. The Kaplan-Meier method was used to plot the curves of rebleeding rate, shunt dysfunction rate, and survival rate, and the Log-rank test was used for the comparison of cumulative rebleeding rate, shunt dysfunction rate, and survival rate. The Cox proportional hazards regression model was used for univariate and multivariate analyses. ResultsAll 142 patients completed the surgery successfully. There were no significant differences between the TIPS group and the TIPS+SEVE group in mean follow-up time (34±23 months vs 32±21 months, t=0.501, P>0.05) and incidence rate of hepatic encephalopathy after surgery (12.9% vs 18.9%, χ2=0.641, P>005). There were no significant differences between the TIPS group and the TIPS+SEVE group in 1-, 2-, 3-, and 5-year cumulative rebleeding rates during follow-up (χ2=1.511, P>0.05), while there were significant differences between the two groups in 1-, 2-, 3-, and 5-year cumulative shunt dysfunction rates (13%/21%/34%/34% vs 7%/12%/13%/13%, χ2=4.087, P<0.05). There were no significant differences between the two groups in 1-, 2-, 3-, and 5-year cumulative survival rates during follow-up (χ2=0471, P>0.05). Preoperative Child-Pugh class (hazard ratio [HR]=0.385, 95% confidence interval [CI]: 0.165-0.898, P<005), stent type (HR=0.429, 95%CI: 0.240-0.766, P<0.05), and postoperative shunt dysfunction (HR=5.840, 95%CI: 2566-13.294, P<0.05) were influencing factors for postoperative rebleeding in cirrhotic patients with gastroesophageal variceal bleeding. The multivariate analysis showed that bare stent (relative risk [RR]=0.527, 95%CI: 0.290-0.954, P<0.05) and postoperative shunt dysfunction (RR=4.436, 95%CI: 1.899-10.360, P<0.05) were independent risk factors for postoperative rebleeding in cirrhotic patients with gastroesophageal variceal bleeding. ConclusionCompared with TIPS alone, TIPS+SEVE can reduce the incidence rate of postoperative shunt dysfunction in cirrhotic patients with gastroesophageal variceal bleeding, but it cannot reduce postoperative rebleeding rate or increase survival rate. Bare stent and shunt dysfunction are independent risk factors for postoperative rebleeding in cirrhotic patients with gastroesophageal variceal bleeding.
【关键字】:肝硬化; 食管和胃静脉曲张; 门体分流术, 经颈静脉肝内
【Key words】:liver cirrhosis; esophageal and gastric varices; portasystemic shunt, transjugular intrahepatic
【引证本文】:
CHEN M, ZHANG F, ZHANG M, et al. Clinical effect of transjugular intrahepatic portosystemic shunt combined with tissue adhesive embolization in treatment of gastroesophageal variceal rebleeding in cirrhotic patients[J]. J Clin Hepatol, 2018, 34(6): 1209-1214. (in Chinese) 陈敏, 张峰, 张明, 等. 经颈静脉肝内门体分流术联合组织胶栓塞术治疗肝硬化食管胃静脉曲张再出血的效果分析[J]. 临床肝胆病杂志, 2018, 34(6): 1209-1214.

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