经颈静脉门体静脉分流术治疗肝硬化患者难治性肝性胸水

liver411

Transjugular intrahepatic portosystemic shunt for symptomatic refractory hepatic hydrothorax in patients with cirrhosis.
出处：Am J Gastroenterol   2010  Mar  105(3) :635-41
作者：Dhanasekaran R;West JK;Gonzales PC;Subramanian Rarekh S;Spivey JR;Martin LG;Kim HS
PMID：19904245

目的：我们探寻研究肝硬化并有症状的难治性肝性胸水患者（TIPS）经颈静脉门体静脉分流术后的疗效、生存期和并发症。

方法：回顾性分析1992年1月至2008年12月因肝性胸水而接受经颈静脉门体静脉分流术的连续性患者。收集所有患者临床、实验室和程序性资料并做回顾性病历分析。应用卡方检验比较分类变量，t -检验比较连续变量。采用Kaplan-Meier 进行生存分析。生存曲线比较采用log - rank检验。

结果：本研究共纳入73例患者，患TIPS时的平均年龄为55.62岁（标准差11.65）。术前和术后的平均门体循环梯度分别为18.9（标准差4.7）毫米汞柱和5.7（标准差2.4）毫米汞柱性（P <0.001）。 1个月内和6个月时的临床良好反应率分别为79％（58/73）和75％（30/40）。研究组的平均存活期为517天（95％可信区间为 11-626）。30天、60天和90天的短期生存率分别为81%、78%和72％。1年、3年和5年的长期生存率别为48%、265和15％。Cox比例项危险模型方法多变量分析表明，TIPS 术前终末期肝病（MELD）模型评分（P = 0.039，危险比为1.9（95％可信区间为1.0-3.7）和临床反应（P = 0.003，危险比为2.5，95％可信区间为1.4-4.5）与总生存率显著和独立相关。30天死亡率为19％，TIPS术前肌酸酐水平与30天死亡率显著相关（P = 0.024，危险比为3.42，95％可信区间为1.2-9.9）。

结论：TIPS 成功用于缓解难治性肝性胸水症状，术后较好的临床反应和术前MELD评分小于15与术后较长生存期有关。

OBJECTIVES: We sought to study effectiveness, survival, and complications after transjugular intrahepatic portosystemic shunt (TIPS) in patients with cirrhosis and symptomatic refractory hepatic hydrothorax. METHODS: Consecutive patients who underwent TIPS between January 1992 and December 2008 for refractory hydrothorax were reviewed retrospectively. Clinical, laboratory, and procedural data were collected for all patients by retrospective chart review. Chi-square test was used to compare categorical variables and t-test to compare continuous variables. The Kaplan-Meier method was used for survival analysis. Survival curves were compared using the log-rank test. RESULTS: Seventy-three patients were included in the study, and their mean age at TIPS creation was 55.62 years (s.d. 11.65). The mean pre- and post-TIPS portosystemic gradients were 18.9 (s.d. 4.7) mm Hg and 5.7 (s.d. 2.4) mm Hg (P<0.001), respectively. The rates of favorable clinical response within 1 month and at 6 months after TIPS were 79% (58/73) and 75% (30/40), respectively. Median survival of the study group was 517 days (95% CI 11-626). The short-term survival rates at 30, 60, and 90 days were 81, 78, and 72%, respectively. The long-term survival rates at 1, 3, and 5 years were 48, 26, and 15%, respectively. Multivariate analysis by Cox proportional hazards method showed that pre-TIPS model for end-stage liver disease (MELD) score (P=0.039, HR 1.9 (95% CI 1.0-3.7)) and clinical response (P=0.003, HR 2.5 (95% CI 1.4-4.5)) were significantly and independently associated with overall survival. The 30-day mortality rate was 19%. Pre-TIPS creatinine levels (P=0.024, HR 3.42 (95% CI 1.2-9.9)) were significantly associated with 30-day mortality. CONCLUSIONS: TIPS can be successfully used to achieve symptomatic relief in patients with refractory hepatic hydrothorax. Better clinical response after TIPS and pre-TIPS MELD score less than 15 were associated with longer survival after TIPS.

专家评价：
Mario Cottone
University of Palermo, Italy
Gastroenterology & Hepatology

Hepatic hydrothorax in cirrhosis is a complication that is difficult to treat. Until recently, no effective treatment was available. Previous small series have shown that transjugular intrahepatic portosystemic shunt (TIPS) is a possible treatment {1-5}. This article adds evidence to the possibility that TIPS is a viable treatment option. A six-month 75% response rate in this study is relevant. Prognostic variables of the response are identified.

The authors show that TIPS can be successfully used to achieve symptomatic relief in patients with refractory hepatic hydrothorax. A better clinical response after TIPS and a pre-TIPS model for end-stage liver disease (MELD) score of less than 15 were associated with longer survival after TIPS. The main strength of the study is that it reviews the largest series of patients to date in order to assess the role for TIPS in patients with hydrothorax in cirrhosis. The weakness is that there is not a control population, which could add strength to the results. The retrospective design of the study and the relatively short duration of follow-up can also be considered to be limitations of the study. A controlled trial of TIPS versus diuretic therapy together with intermittent thoracocentesis is warranted. These results suggest that guidelines for liver disease should incorporate the use of TIPS in portal hypertension and recognize refractory hydrothorax as one of the indications for TIPS. A clear indication for TIPS in patients with resistant hydrothorax is advisable on the basis of this study.

References: {1} Degawa et al. J Gastroenterol 1999, 34:128-31 [PMID:10204623]. {2} Kidokoro et al. Nippon Shokakibyo Gakkai Zasshi 2003, 100:707-12 [PMID:12833867]. {3} Haskal and Zuckerman, Chest 1994, 106:1293-5 [PMID:7924523]. {4} Gordon et al. Hepatology 1997, 25:1366-9 [PMID:9185754]. {5} Jeffries et al. Liver Transpl Surg 1998, 4:416-23 [PMID:9724480]. {6} Spencer et al. J Vasc Interv Radiol 2002, 13:385-90 [PMID:11932369].



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