Ascites is one of the major complications of liver cirrhosis and is associated with a poor prognosis. It is important to distinguish noncirrhotic from cirrhotic causes of ascites to guide therapy in patients with nonc...Ascites is one of the major complications of liver cirrhosis and is associated with a poor prognosis. It is important to distinguish noncirrhotic from cirrhotic causes of ascites to guide therapy in patients with noncirrhotic ascites. Mild to moderate ascites is treated by salt restriction and diuretic therapy. The diuretic of choice is spironolactone. A combination treatment with furosemide might be necessary in patients who do not respond to spironolactone alone. Tense ascites is treated by paracentesis, followed by albumin infusion and diuretic therapy. Treatment options for refractory ascites include repeated paracentesis and transjugular intrahepatic portosystemic shunt placement in patients with a preserved liver function. Potential complications of ascites are spontaneous bacterial peritonitis (SBP) and hepatorenal syndrome (HRS). SBP is diagnosed by an ascitic neutrophil count > 250 cells/mm3 and is treated with antibiotics. Patients who survive a first episode of SBP or with a low protein concentration in the ascitic fluid require an antibiotic prophylaxis. The prognosis of untreated HRS type 1 is grave. Treatment consists of a combination of terlipressin and albumin. Hemodialysis might serve in selected patients as a bridging therapy to liver transplantation. Liver transplantation should be considered in all patients with ascites and liver cirrhosis.展开更多
The congenital dyserythropoietic anemias comprise a group of rare hereditary disorders of erythropoiesis, characterized by ineffective erythropoiesis as the predominant mechanism of anemia and by characteristic morpho...The congenital dyserythropoietic anemias comprise a group of rare hereditary disorders of erythropoiesis, characterized by ineffective erythropoiesis as the predominant mechanism of anemia and by characteristic morphological aberrations of the majority of erythroblasts in the bone marrow. Congenital dyserythropoietic anemia type II is the most frequent type. All types of congenital dyserythropoietic anemias distinctly share a high incidence of iron loading. Iron accumulation occurs even in untransfused patients and can result in heart failure and liver cirrhosis. We have reported about a patient who presented with liver cirrhosis and intractable ascites caused by congenital dyserythropoietic anemia type II. Her clinical course was further complicated by the development of autoimmune hemolytic anemia. Splenectomy was eventually performed which achieved complete resolution of ascites, increase of hemoglobin concentration and abrogation of transfusion requirements.展开更多
More than five decades after it was originally conceptualized as rescue therapy for patients with intractable variceal bleeding,the transjugular intrahepatic portosystemic shunt(TIPS)procedure continues to remain a fo...More than five decades after it was originally conceptualized as rescue therapy for patients with intractable variceal bleeding,the transjugular intrahepatic portosystemic shunt(TIPS)procedure continues to remain a focus of intense clinical and biomedical research.By the impressive reduction in portal pressure achieved by this intervention,coupled with its minimally invasive nature,TIPS has gained increasing acceptance in the treatment of complications of portal hypertension.The early years of TIPS were plagued by poor long-term patency of the stents and increased incidence of hepatic encephalopathy.Moreover,the diversion of portal flow after placement of TIPS often resulted in derangement of hepatic functions,which was occasionally severe.While the incidence of shunt dysfunction has markedly reduced with the advent of covered stents,hepatic encephalopathy and instances of early liver failure continue to remain a significant issue after TIPS.It has emerged over the years that careful selection of patients and diligent post-procedural care is of paramount importance to optimize the outcome after TIPS.The past twenty years have seen multiple studies redefining the role of TIPS in the management of variceal bleeding and refractory ascites while exploring its application in other complications of cirrhosis like hepatic hydrothorax,portal hypertensive gastropathy,ectopic varices,hepatorenal and hepatopulmonary syndromes,non-tumoral portal vein thrombosis and chylous ascites.It has also been utilized to good effect before extrahepatic abdominal surgery to reduce perioperative morbidity and mortality.The current article aims to review the updated literature on the status of TIPS in the management of patients with liver cirrhosis.展开更多
Background：One-lung ventilation （OLV） is a common ventilation technology during thoracic surgery that can cause serious clinical problems.We aimed to conduct a meta-analysis to compare oxygenation and intrapulmonar...Background：One-lung ventilation （OLV） is a common ventilation technology during thoracic surgery that can cause serious clinical problems.We aimed to conduct a meta-analysis to compare oxygenation and intrapulmonary shunt during OLV in adults undergoing thoracic surgery with dexmedetomidine （Dex） versus placebo to assess the influence and safety of using Dex.Methods：Randomized controlled trials comparing lung protection in patients who underwent thoracic surgery with Dex or a placebo were retrieved from PubMed,EMBASE,MEDLINE,Cochrane Library,and China CNKI database.The following information was extracted from the paper：arterial oxygen partial pressure （PaO2）,PaO2/inspired oxygen concentration （PaO2/FiO2,oxygenation index [OI]）,intrapulmonary shunt （calculated as Qs/Qt）,mean arterial pressure （MAP）,heart rate （HR）,tumor necrosis factor-α （TNF-α）,interleukin （IL）-6,superoxide dismutase （SOD）,and malondialdehyde （MDA）.Results：Fourteen randomized controlled trials were included containing a total of 625 patients.Compared with placebo group,Dex significantly increased PaO2/FiO2 （standard mean difference [SMD] =0.98,95% confidence interval [CI] [0.72,1.23],P 〈 0.00001）.Besides,Qs/Qt （SMD=-1.22,95% CI [-2.20,-0.23],P =0.020）,HR （SMD=-0.69,95% CI [-1.20,0.17],P =0.009）,MAP （SMD=-0.44,95% CI [-0.84,0.04],P =0.030）,the concentrations ofTNF-α （SMD =-1.55,95% CI [-2.16,-0.95],P 〈0.001）,and IL-6 （SMD =-1.53,95% CI [-2.37,-0.70],P =0.0003） were decreased in the treated group,when compared to placebo group.No significant difference was found in MDA （SMD =-1.14,95% CI [-3.48,1.20],P =0.340） and SOD （SMD =0.41,95% CI [-0.29,1.10],P =0.250） between the Dex group and the placebo group.Funnel plots did not detect any significant publication bias.Conclusions：Dex may improve OI and reduce intrapulmonary shunt during OLV in adults undergoing thoracic surgery.However,this conclusion might be weakened by the limited number of pooled studies and p展开更多
AIM: To compare the liver transplantation-free (LTF) survival rates between patients who underwent transjugular intrahepatic portosystemic shunts (TIPS) and those who underwent paracentesis by an updated meta-analysis...AIM: To compare the liver transplantation-free (LTF) survival rates between patients who underwent transjugular intrahepatic portosystemic shunts (TIPS) and those who underwent paracentesis by an updated meta-analysis that pools the effects of both number of deaths and time to death.展开更多
AIM: To evaluate the effect of the shunting branch of the portal vein (PV) (left or right) and the initial stent position (optimal or suboptimal) of a transjugular intrahepatic portosystemic shunt (TIPS).
AIM:To determine the clinical effects and complications of transjugular intrahepatic portosystemic shunt(TIPS)for portal hypertension due to cirrhosis.METHODS:Two hundred and eighty patients with portal hypertension d...AIM:To determine the clinical effects and complications of transjugular intrahepatic portosystemic shunt(TIPS)for portal hypertension due to cirrhosis.METHODS:Two hundred and eighty patients with portal hypertension due to cirrhosis who underwent TIPS were retrospectively evaluated.Portal trunk pressure was measured before and after surgery.The changes in hemodynamics and the condition of the stent were assessed by ultrasound and the esophageal and fundic veins observed endoscopically.RESULTS:The success rate of TIPS was 99.3%.The portal trunk pressure was 26.8±3.6 cmH2O after surgery and 46.5±3.4 cmH2O before surgery(P<0.01).The velocity of blood flow in the portal vein increased.The internal diameters of the portal and splenic veins were reduced.The short-term hemostasis rate was100%.Esophageal varices disappeared completely in68%of patients and were obviously reduced in 32%.Varices of the stomach fundus disappeared completely in 80%and were obviously reduced in 20%of patients.Ascites disappeared in 62%,were markedly reduced in 24%,but were still apparent in 14%of patients.The total effective rate of ascites reduction was 86%.Hydrothorax completely disappeared in 100%of patients.The incidence of post-operative stent stenosis was 24%at 12 mo and 34%at 24 mo.The incidence of post-operative hepatic encephalopathy was 12%at3 mo,17%at 6 mo and 19%at 12 mo.The incidence of post-operative recurrent hemorrhage was 9%at 12mo,19%at 24 mo and 35%at 36 mo.The cumulative survival rate was 86%at 12 mo,81%at 24 mo,75%at 36 mo,57%at 48 mo and 45%at 60 mo.CONCLUSION:TIPS can effectively lower portal hypertension due to cirrhosis.It is significantly effective for hemorrhage of the digestive tract due to rupture of esophageal and fundic veins and for ascites and hydrothorax caused by portal hypertension.展开更多
Acute variceal hemorrhage,a life-threatening condition that requires a multidisciplinary approach for effective therapy,is defined as visible bleeding from an esophageal or gastric varix at the time of endoscopy,the p...Acute variceal hemorrhage,a life-threatening condition that requires a multidisciplinary approach for effective therapy,is defined as visible bleeding from an esophageal or gastric varix at the time of endoscopy,the presence of large esophageal varices with recent stigmata of bleeding,or fresh blood visible in the stomach with no other source of bleeding identified.Transfusion of blood products,pharmacological treatments and early endoscopic therapy are often effective;however,if primary hemostasis cannot be obtained or if uncontrollable early rebleeding occurs,transjugular intrahepatic portosystemic shunt(TIPS)is recommended as rescue treatment.The TIPS represents a major advance in the treatment of complications of portal hypertension.Acute variceal hemorrhage that is poorly controlled with endoscopic therapy is generally well controlled with TIPS,which has a 90%to 100%success rate.However,TIPS is associated with a mortality of 30%to 50%in such a setting.Emergency TIPS should be considered early in patients with refractory variceal bleeding once medical treatment and endoscopic sclerotherapy failure,before the clinical condition worsens.Furthermore,admission to specialized centers is mandatory in such a setting and regional protocols are essential to be organized effectively.This review article discusses initial management and then focuses on the specific role of TIPS as a primary therapy to control acute variceal hemorrhage,particularly as a rescue therapy following failure of endoscopic approaches.展开更多
BACKGROUND Transjugular intrahepatic portosystemic shunt(TIPS) is currently used for the treatment of complications of portal hypertension. The incidence of hepatic encephalopathy(HE) remains a problem in TIPS placeme...BACKGROUND Transjugular intrahepatic portosystemic shunt(TIPS) is currently used for the treatment of complications of portal hypertension. The incidence of hepatic encephalopathy(HE) remains a problem in TIPS placement. It has been reported that the right branch mainly receives superior mesenteric venous blood while the left branch mainly receives blood from the splenic vein. We hypothesized that targeted puncture of the left portal vein would divert the non-nutritive blood from the splenic vein into the TIPS shunt; therefore, targeted puncture of the left branch of the intrahepatic portal vein during TIPS may reduce the risk of HE.AIM To evaluate the influence of targeted puncture of left branch of portal vein in TIPS on HE.METHODS A retrospective analysis of 1244 patients with portal-hypertension-related complications of refractory ascites or variceal bleeding who underwent TIPS from January 2000 to January 2013 was performed. Patients were divided into group A(targeting left branch of portal vein, n = 937) and group B(targeting right branch of portal vein, n = 307). TIPS-related HE and clinical outcomes were analyzed.RESULTS The symptoms of ascites and variceal bleeding disappeared within a short time.By the endpoint of follow-up, recurrent bleeding and ascites did not differ significantly between groups A and B(P = 0.278, P = 0.561, respectively).Incidence of HE differed significantly between groups A and B at 1 mo(14.94% vs36.80%, χ~2 = 4.839, P = 0.028), 3 mo(12.48% vs 34.20%, χ~2 = 5.054, P = 0.025), 6 mo(10.03% vs 32.24%, χ~2 = 6.560, P = 0.010), 9 mo(9.17% vs 31.27%, χ~2 = 5.357, P =0.021), and 12 mo(8.21% vs 28.01, χ~2 = 3.848, P = 0.051). There were no significant differences between groups A and B at 3 years(6.61% vs 7.16%, χ~2 = 1.204, P =0.272) and 5 years(5.01% vs 6.18%, χ~2 = 0.072, P = 0.562). The total survival rate did not differ between groups A and B(χ~2 = 0.226, P = 0.634, log-rank test).CONCLUSION Targeted puncture of the left branch of the intrahepatic portal vein during TIPS may 展开更多
AIM To compare the outcomes of transcatheter superior mesenteric artery(SMA) urokinase infusion and transjugular intrahepatic portosystemic shunt(TIPS) for acute portal vein thrombosis(PVT) in cirrhosis.METHODS From J...AIM To compare the outcomes of transcatheter superior mesenteric artery(SMA) urokinase infusion and transjugular intrahepatic portosystemic shunt(TIPS) for acute portal vein thrombosis(PVT) in cirrhosis.METHODS From January 2013 to December 2014, patients with liver cirrhosis and acute symptomatic PVT who met the inclusion criteria were randomly assigned to either an SMA group or a TIPS group. The two groups accepted transcatheter selective SMA urokinase infusion therapyand TIPS, respectively. The total follow-up time was24 mo. The primary outcome measure was the change in portal vein patency status which was evaluated by angio-computed tomography or Doppler ultrasound.Secondary outcomes were rebleeding and hepatic encephalopathy.RESULTS A total of 40 patients were enrolled, with 20 assigned to the SMA group and 20 to the TIPS group. The symptoms of all patients in the two groups improved within 48 h. PVT was improved in 17(85%) patients in the SMA group and 14(70%) patients in the TIPS group. The main portal vein(MPV) thrombosis was significantly reduced in both groups(P < 0.001), and there was no significant difference between them(P= 0.304). In the SMA group, superior mesenteric vein(SMV) thrombosis and splenic vein(SV) thrombosis were significantly reduced(P = 0.048 and P = 0.02),which did not occur in the TIPS group. At 6-, 12-,and 24-mo follow-up, in the SMA group and the TIPS group, the cumulative rates free of the first episode of rebleeding were 80%, 65%, and 45% vs 90%, 80%,and 60%, respectively(P = 0.320); the cumulative rates free of the first episode of hepatic encephalopathy were 85%, 80%, and 65% vs 50%, 40%, and 35%,respectively(P = 0.022).CONCLUSION Transcatheter selective SMA urokinase infusion and TIPS are safe and effective for acute symptomatic PVT in cirrhosis.展开更多
BACKGROUND： Transjugular intrahepatic portosystemic shunt（TIPS） and open splenectomy and esophagogastric devascularization（OSED） are widely used to treat patients with portal hypertension and recurrent variceal b...BACKGROUND： Transjugular intrahepatic portosystemic shunt（TIPS） and open splenectomy and esophagogastric devascularization（OSED） are widely used to treat patients with portal hypertension and recurrent variceal bleeding（PHRVB）. This study aimed to compare the effectiveness between TIPS and OSED for the treatment of PHRVB.METHODS： The data were retrospectively retrieved from 479 cirrhotic patients（Child-Pugh A or B class） with PHRVB, who had undergone TIPS（TIPS group） or OSED（OSED group） between January 1, 2010 and October 31, 2014.RESULTS： A total of 196 patients received TIPS, whereas 283 underwent OSED. Within one month after TIPS and OSED, the rebleeding rates were 6.1% and 3.2%, respectively（P=0.122）. Significantly lower incidence of pleural effusion,splenic vein thrombosis, and pulmonary infection, as well as higher hepatic encephalopathy rate, shorter postoperative length of hospital stay, and higher hospital costs were observed in the TIPS group than those in the OSED group. During the follow-up periods（29 months）, significantly higher incidences of rebleeding（15.3% vs 4.6%, P=0.001） and hepatic encephalopathy（17.3% vs 3.9%, P=0.001） were observed in the TIPS group than in the OSED group. The incidence of instent stenosis was 18.9%. The survival rates were 91.3% in the TIPS group and 95.1% in the OSED group. The long-term liver function did not worsen after either TIPS or OSED.CONCLUSION： For the patients with liver function in the Child-Pugh A or B class, TIPS is not superior over OSED in terms of PHRVB treatment and rebleeding prevention.展开更多
AIM: To evaluate the effect of portal vein thrombosis and arterioportal shunts on local tumor response in advanced cases of unresectable hepatocellular carcinoma treated by transarterial chemoembolization. METHODS: A ...AIM: To evaluate the effect of portal vein thrombosis and arterioportal shunts on local tumor response in advanced cases of unresectable hepatocellular carcinoma treated by transarterial chemoembolization. METHODS: A retrospective study included 39 patients (mean age: 66.4 years, range: 45-79 years, SD: 7) with unresectable hepatocellular carcinoma (HCC) who were treated with repetitive transarterial chemoembolization (TACE) in the period between March 2006 and October 2009. The effect of portal vein thrombosis (PVT) (in 19 out of 39 patients), the presence of arterioportal shunt (APS) (in 7 out of 39), the underlying liver pathology,Child-Pugh score, initial tumor volume, number of tumors and tumor margin definition on imaging were correlated with the local tumor response after TACE. The initial and end therapy local tumor responses were evaluated according to the response evaluation criteria in solid tumors (RECIST) and magnetic resonance imaging volumetric measurements. RESULTS: The treatment protocols were well tolerated by all patients with no major complications. Local tumor response for all patients according to RECIST criteria were partial response in one patient (2.6%), stable disease in 34 patients (87.1%), and progressive disease in 4 patients (10.2%). The MR volumetric measurements showed that the PVT, APS, underlying liver pathology and tumor margin definition were statistically significant prognostic factors for the local tumor response (P = 0.018, P = 0.008, P = 0.034 and P = 0.001, respectively). The overall 6-, 12- and 18-mo survival rates from the initial TACE were 79.5%, 37.5% and 21%, respectively. CONCLUSION: TACE may be exploited safely for palliative tumor control in patients with advanced unresectable HCC; however, tumor response is significantly affected by the presence or absence of PVT and APS.展开更多
文摘Ascites is one of the major complications of liver cirrhosis and is associated with a poor prognosis. It is important to distinguish noncirrhotic from cirrhotic causes of ascites to guide therapy in patients with noncirrhotic ascites. Mild to moderate ascites is treated by salt restriction and diuretic therapy. The diuretic of choice is spironolactone. A combination treatment with furosemide might be necessary in patients who do not respond to spironolactone alone. Tense ascites is treated by paracentesis, followed by albumin infusion and diuretic therapy. Treatment options for refractory ascites include repeated paracentesis and transjugular intrahepatic portosystemic shunt placement in patients with a preserved liver function. Potential complications of ascites are spontaneous bacterial peritonitis (SBP) and hepatorenal syndrome (HRS). SBP is diagnosed by an ascitic neutrophil count > 250 cells/mm3 and is treated with antibiotics. Patients who survive a first episode of SBP or with a low protein concentration in the ascitic fluid require an antibiotic prophylaxis. The prognosis of untreated HRS type 1 is grave. Treatment consists of a combination of terlipressin and albumin. Hemodialysis might serve in selected patients as a bridging therapy to liver transplantation. Liver transplantation should be considered in all patients with ascites and liver cirrhosis.
文摘The congenital dyserythropoietic anemias comprise a group of rare hereditary disorders of erythropoiesis, characterized by ineffective erythropoiesis as the predominant mechanism of anemia and by characteristic morphological aberrations of the majority of erythroblasts in the bone marrow. Congenital dyserythropoietic anemia type II is the most frequent type. All types of congenital dyserythropoietic anemias distinctly share a high incidence of iron loading. Iron accumulation occurs even in untransfused patients and can result in heart failure and liver cirrhosis. We have reported about a patient who presented with liver cirrhosis and intractable ascites caused by congenital dyserythropoietic anemia type II. Her clinical course was further complicated by the development of autoimmune hemolytic anemia. Splenectomy was eventually performed which achieved complete resolution of ascites, increase of hemoglobin concentration and abrogation of transfusion requirements.
文摘More than five decades after it was originally conceptualized as rescue therapy for patients with intractable variceal bleeding,the transjugular intrahepatic portosystemic shunt(TIPS)procedure continues to remain a focus of intense clinical and biomedical research.By the impressive reduction in portal pressure achieved by this intervention,coupled with its minimally invasive nature,TIPS has gained increasing acceptance in the treatment of complications of portal hypertension.The early years of TIPS were plagued by poor long-term patency of the stents and increased incidence of hepatic encephalopathy.Moreover,the diversion of portal flow after placement of TIPS often resulted in derangement of hepatic functions,which was occasionally severe.While the incidence of shunt dysfunction has markedly reduced with the advent of covered stents,hepatic encephalopathy and instances of early liver failure continue to remain a significant issue after TIPS.It has emerged over the years that careful selection of patients and diligent post-procedural care is of paramount importance to optimize the outcome after TIPS.The past twenty years have seen multiple studies redefining the role of TIPS in the management of variceal bleeding and refractory ascites while exploring its application in other complications of cirrhosis like hepatic hydrothorax,portal hypertensive gastropathy,ectopic varices,hepatorenal and hepatopulmonary syndromes,non-tumoral portal vein thrombosis and chylous ascites.It has also been utilized to good effect before extrahepatic abdominal surgery to reduce perioperative morbidity and mortality.The current article aims to review the updated literature on the status of TIPS in the management of patients with liver cirrhosis.
文摘Background：One-lung ventilation （OLV） is a common ventilation technology during thoracic surgery that can cause serious clinical problems.We aimed to conduct a meta-analysis to compare oxygenation and intrapulmonary shunt during OLV in adults undergoing thoracic surgery with dexmedetomidine （Dex） versus placebo to assess the influence and safety of using Dex.Methods：Randomized controlled trials comparing lung protection in patients who underwent thoracic surgery with Dex or a placebo were retrieved from PubMed,EMBASE,MEDLINE,Cochrane Library,and China CNKI database.The following information was extracted from the paper：arterial oxygen partial pressure （PaO2）,PaO2/inspired oxygen concentration （PaO2/FiO2,oxygenation index [OI]）,intrapulmonary shunt （calculated as Qs/Qt）,mean arterial pressure （MAP）,heart rate （HR）,tumor necrosis factor-α （TNF-α）,interleukin （IL）-6,superoxide dismutase （SOD）,and malondialdehyde （MDA）.Results：Fourteen randomized controlled trials were included containing a total of 625 patients.Compared with placebo group,Dex significantly increased PaO2/FiO2 （standard mean difference [SMD] =0.98,95% confidence interval [CI] [0.72,1.23],P 〈 0.00001）.Besides,Qs/Qt （SMD=-1.22,95% CI [-2.20,-0.23],P =0.020）,HR （SMD=-0.69,95% CI [-1.20,0.17],P =0.009）,MAP （SMD=-0.44,95% CI [-0.84,0.04],P =0.030）,the concentrations ofTNF-α （SMD =-1.55,95% CI [-2.16,-0.95],P 〈0.001）,and IL-6 （SMD =-1.53,95% CI [-2.37,-0.70],P =0.0003） were decreased in the treated group,when compared to placebo group.No significant difference was found in MDA （SMD =-1.14,95% CI [-3.48,1.20],P =0.340） and SOD （SMD =0.41,95% CI [-0.29,1.10],P =0.250） between the Dex group and the placebo group.Funnel plots did not detect any significant publication bias.Conclusions：Dex may improve OI and reduce intrapulmonary shunt during OLV in adults undergoing thoracic surgery.However,this conclusion might be weakened by the limited number of pooled studies and p
文摘AIM: To compare the liver transplantation-free (LTF) survival rates between patients who underwent transjugular intrahepatic portosystemic shunts (TIPS) and those who underwent paracentesis by an updated meta-analysis that pools the effects of both number of deaths and time to death.
文摘AIM: To evaluate the effect of the shunting branch of the portal vein (PV) (left or right) and the initial stent position (optimal or suboptimal) of a transjugular intrahepatic portosystemic shunt (TIPS).
基金Supported by The grant from Chengdu Military General Hospital,No.424121HK
文摘AIM:To determine the clinical effects and complications of transjugular intrahepatic portosystemic shunt(TIPS)for portal hypertension due to cirrhosis.METHODS:Two hundred and eighty patients with portal hypertension due to cirrhosis who underwent TIPS were retrospectively evaluated.Portal trunk pressure was measured before and after surgery.The changes in hemodynamics and the condition of the stent were assessed by ultrasound and the esophageal and fundic veins observed endoscopically.RESULTS:The success rate of TIPS was 99.3%.The portal trunk pressure was 26.8±3.6 cmH2O after surgery and 46.5±3.4 cmH2O before surgery(P<0.01).The velocity of blood flow in the portal vein increased.The internal diameters of the portal and splenic veins were reduced.The short-term hemostasis rate was100%.Esophageal varices disappeared completely in68%of patients and were obviously reduced in 32%.Varices of the stomach fundus disappeared completely in 80%and were obviously reduced in 20%of patients.Ascites disappeared in 62%,were markedly reduced in 24%,but were still apparent in 14%of patients.The total effective rate of ascites reduction was 86%.Hydrothorax completely disappeared in 100%of patients.The incidence of post-operative stent stenosis was 24%at 12 mo and 34%at 24 mo.The incidence of post-operative hepatic encephalopathy was 12%at3 mo,17%at 6 mo and 19%at 12 mo.The incidence of post-operative recurrent hemorrhage was 9%at 12mo,19%at 24 mo and 35%at 36 mo.The cumulative survival rate was 86%at 12 mo,81%at 24 mo,75%at 36 mo,57%at 48 mo and 45%at 60 mo.CONCLUSION:TIPS can effectively lower portal hypertension due to cirrhosis.It is significantly effective for hemorrhage of the digestive tract due to rupture of esophageal and fundic veins and for ascites and hydrothorax caused by portal hypertension.
文摘Acute variceal hemorrhage,a life-threatening condition that requires a multidisciplinary approach for effective therapy,is defined as visible bleeding from an esophageal or gastric varix at the time of endoscopy,the presence of large esophageal varices with recent stigmata of bleeding,or fresh blood visible in the stomach with no other source of bleeding identified.Transfusion of blood products,pharmacological treatments and early endoscopic therapy are often effective;however,if primary hemostasis cannot be obtained or if uncontrollable early rebleeding occurs,transjugular intrahepatic portosystemic shunt(TIPS)is recommended as rescue treatment.The TIPS represents a major advance in the treatment of complications of portal hypertension.Acute variceal hemorrhage that is poorly controlled with endoscopic therapy is generally well controlled with TIPS,which has a 90%to 100%success rate.However,TIPS is associated with a mortality of 30%to 50%in such a setting.Emergency TIPS should be considered early in patients with refractory variceal bleeding once medical treatment and endoscopic sclerotherapy failure,before the clinical condition worsens.Furthermore,admission to specialized centers is mandatory in such a setting and regional protocols are essential to be organized effectively.This review article discusses initial management and then focuses on the specific role of TIPS as a primary therapy to control acute variceal hemorrhage,particularly as a rescue therapy following failure of endoscopic approaches.
文摘BACKGROUND Transjugular intrahepatic portosystemic shunt(TIPS) is currently used for the treatment of complications of portal hypertension. The incidence of hepatic encephalopathy(HE) remains a problem in TIPS placement. It has been reported that the right branch mainly receives superior mesenteric venous blood while the left branch mainly receives blood from the splenic vein. We hypothesized that targeted puncture of the left portal vein would divert the non-nutritive blood from the splenic vein into the TIPS shunt; therefore, targeted puncture of the left branch of the intrahepatic portal vein during TIPS may reduce the risk of HE.AIM To evaluate the influence of targeted puncture of left branch of portal vein in TIPS on HE.METHODS A retrospective analysis of 1244 patients with portal-hypertension-related complications of refractory ascites or variceal bleeding who underwent TIPS from January 2000 to January 2013 was performed. Patients were divided into group A(targeting left branch of portal vein, n = 937) and group B(targeting right branch of portal vein, n = 307). TIPS-related HE and clinical outcomes were analyzed.RESULTS The symptoms of ascites and variceal bleeding disappeared within a short time.By the endpoint of follow-up, recurrent bleeding and ascites did not differ significantly between groups A and B(P = 0.278, P = 0.561, respectively).Incidence of HE differed significantly between groups A and B at 1 mo(14.94% vs36.80%, χ~2 = 4.839, P = 0.028), 3 mo(12.48% vs 34.20%, χ~2 = 5.054, P = 0.025), 6 mo(10.03% vs 32.24%, χ~2 = 6.560, P = 0.010), 9 mo(9.17% vs 31.27%, χ~2 = 5.357, P =0.021), and 12 mo(8.21% vs 28.01, χ~2 = 3.848, P = 0.051). There were no significant differences between groups A and B at 3 years(6.61% vs 7.16%, χ~2 = 1.204, P =0.272) and 5 years(5.01% vs 6.18%, χ~2 = 0.072, P = 0.562). The total survival rate did not differ between groups A and B(χ~2 = 0.226, P = 0.634, log-rank test).CONCLUSION Targeted puncture of the left branch of the intrahepatic portal vein during TIPS may
基金Supported by the National Natural Science Foundation of China,No.81572888
文摘AIM To compare the outcomes of transcatheter superior mesenteric artery(SMA) urokinase infusion and transjugular intrahepatic portosystemic shunt(TIPS) for acute portal vein thrombosis(PVT) in cirrhosis.METHODS From January 2013 to December 2014, patients with liver cirrhosis and acute symptomatic PVT who met the inclusion criteria were randomly assigned to either an SMA group or a TIPS group. The two groups accepted transcatheter selective SMA urokinase infusion therapyand TIPS, respectively. The total follow-up time was24 mo. The primary outcome measure was the change in portal vein patency status which was evaluated by angio-computed tomography or Doppler ultrasound.Secondary outcomes were rebleeding and hepatic encephalopathy.RESULTS A total of 40 patients were enrolled, with 20 assigned to the SMA group and 20 to the TIPS group. The symptoms of all patients in the two groups improved within 48 h. PVT was improved in 17(85%) patients in the SMA group and 14(70%) patients in the TIPS group. The main portal vein(MPV) thrombosis was significantly reduced in both groups(P < 0.001), and there was no significant difference between them(P= 0.304). In the SMA group, superior mesenteric vein(SMV) thrombosis and splenic vein(SV) thrombosis were significantly reduced(P = 0.048 and P = 0.02),which did not occur in the TIPS group. At 6-, 12-,and 24-mo follow-up, in the SMA group and the TIPS group, the cumulative rates free of the first episode of rebleeding were 80%, 65%, and 45% vs 90%, 80%,and 60%, respectively(P = 0.320); the cumulative rates free of the first episode of hepatic encephalopathy were 85%, 80%, and 65% vs 50%, 40%, and 35%,respectively(P = 0.022).CONCLUSION Transcatheter selective SMA urokinase infusion and TIPS are safe and effective for acute symptomatic PVT in cirrhosis.
文摘BACKGROUND： Transjugular intrahepatic portosystemic shunt（TIPS） and open splenectomy and esophagogastric devascularization（OSED） are widely used to treat patients with portal hypertension and recurrent variceal bleeding（PHRVB）. This study aimed to compare the effectiveness between TIPS and OSED for the treatment of PHRVB.METHODS： The data were retrospectively retrieved from 479 cirrhotic patients（Child-Pugh A or B class） with PHRVB, who had undergone TIPS（TIPS group） or OSED（OSED group） between January 1, 2010 and October 31, 2014.RESULTS： A total of 196 patients received TIPS, whereas 283 underwent OSED. Within one month after TIPS and OSED, the rebleeding rates were 6.1% and 3.2%, respectively（P=0.122）. Significantly lower incidence of pleural effusion,splenic vein thrombosis, and pulmonary infection, as well as higher hepatic encephalopathy rate, shorter postoperative length of hospital stay, and higher hospital costs were observed in the TIPS group than those in the OSED group. During the follow-up periods（29 months）, significantly higher incidences of rebleeding（15.3% vs 4.6%, P=0.001） and hepatic encephalopathy（17.3% vs 3.9%, P=0.001） were observed in the TIPS group than in the OSED group. The incidence of instent stenosis was 18.9%. The survival rates were 91.3% in the TIPS group and 95.1% in the OSED group. The long-term liver function did not worsen after either TIPS or OSED.CONCLUSION： For the patients with liver function in the Child-Pugh A or B class, TIPS is not superior over OSED in terms of PHRVB treatment and rebleeding prevention.
文摘AIM: To evaluate the effect of portal vein thrombosis and arterioportal shunts on local tumor response in advanced cases of unresectable hepatocellular carcinoma treated by transarterial chemoembolization. METHODS: A retrospective study included 39 patients (mean age: 66.4 years, range: 45-79 years, SD: 7) with unresectable hepatocellular carcinoma (HCC) who were treated with repetitive transarterial chemoembolization (TACE) in the period between March 2006 and October 2009. The effect of portal vein thrombosis (PVT) (in 19 out of 39 patients), the presence of arterioportal shunt (APS) (in 7 out of 39), the underlying liver pathology,Child-Pugh score, initial tumor volume, number of tumors and tumor margin definition on imaging were correlated with the local tumor response after TACE. The initial and end therapy local tumor responses were evaluated according to the response evaluation criteria in solid tumors (RECIST) and magnetic resonance imaging volumetric measurements. RESULTS: The treatment protocols were well tolerated by all patients with no major complications. Local tumor response for all patients according to RECIST criteria were partial response in one patient (2.6%), stable disease in 34 patients (87.1%), and progressive disease in 4 patients (10.2%). The MR volumetric measurements showed that the PVT, APS, underlying liver pathology and tumor margin definition were statistically significant prognostic factors for the local tumor response (P = 0.018, P = 0.008, P = 0.034 and P = 0.001, respectively). The overall 6-, 12- and 18-mo survival rates from the initial TACE were 79.5%, 37.5% and 21%, respectively. CONCLUSION: TACE may be exploited safely for palliative tumor control in patients with advanced unresectable HCC; however, tumor response is significantly affected by the presence or absence of PVT and APS.
