腹水患者腹腔穿刺术与经颈静脉肝内门体分流术的比较。

A comparison of paracentesis and transjugular intrahepatic portosystemic shunting in patients with ascites.

作者信息

Rössle M, Ochs A, Gülberg V, Siegerstetter V, Holl J, Deibert P, Olschewski M, Reiser M, Gerbes A L

机构信息

Medizinische Klinik II, Albrecht-Ludwigs-Universität, Department of Gastroenterology, Freiburg, Germany.

出版信息

N Engl J Med. 2000 Jun 8;342(23):1701-7. doi: 10.1056/NEJM200006083422303.

DOI:10.1056/NEJM200006083422303

PMID:10841872

Abstract

BACKGROUND

In patients with cirrhosis and ascites, creation of a transjugular intrahepatic portosystemic shunt may reduce the ascites and improve renal function. However, the benefit of this procedure as compared with that of large-volume paracentesis is uncertain.

METHODS

We randomly assigned 60 patients with cirrhosis and refractory or recurrent ascites (Child-Pugh class B in 42 patients and class C in 18 patients) to treatment with a transjugular shunt (29 patients) or large-volume paracentesis (31 patients). The mean (+/-SD) duration of follow-up was 45+/-16 months among those assigned to shunting and 44+/-18 months among those assigned to paracentesis. The primary outcome was survival without liver transplantation.

RESULTS

Among the patients in the shunt group, 15 died and 1 underwent liver transplantation during the study period, as compared with 23 patients and 2 patients, respectively, in the paracentesis group. The probability of survival without liver transplantation was 69 percent at one year and 58 percent at two years in the shunt group, as compared with 52 percent and 32 percent in the paracentesis group (P=0.11 for the overall comparison, by the log-rank test). In a multivariate analysis, treatment with transjugular shunting was independently associated with survival without the need for transplantation (P=0.02). At three months, 61 percent of the patients in the shunt group and 18 percent of those in the paracentesis group had no ascites (P=0.006). The frequency of hepatic encephalopathy was similar in the two groups. Of the patients assigned to paracentesis in whom this procedure was unsuccessful, 10 received a transjugular shunt a mean of 5.5+/-4 months after randomization; 4 had a response to this rescue treatment.

CONCLUSIONS

In comparison with large-volume paracentesis, the creation of a transjugular intrahepatic portosystemic shunt can improve the chance of survival without liver transplantation in patients with refractory or recurrent ascites.

摘要

背景

在肝硬化腹水患者中，经颈静脉肝内门体分流术可减少腹水并改善肾功能。然而，与大量腹腔穿刺放液相比，该手术的益处尚不确定。

方法

我们将60例肝硬化难治性或复发性腹水患者（42例Child-Pugh B级，18例C级）随机分为经颈静脉分流术治疗组（29例）和大量腹腔穿刺放液组（31例）。分流术组患者的平均（±标准差）随访时间为45±16个月，腹腔穿刺放液组为44±18个月。主要结局是未进行肝移植的生存情况。

结果

在研究期间，分流术组有15例死亡，1例接受了肝移植，腹腔穿刺放液组分别为23例死亡和2例接受肝移植。分流术组未进行肝移植的1年生存率为69%，2年生存率为58%，腹腔穿刺放液组分别为52%和32%（对数秩检验，总体比较P = 0.11）。多因素分析显示，经颈静脉分流术治疗与无需移植的生存独立相关（P = 0.02）。3个月时，分流术组61%的患者无腹水，腹腔穿刺放液组为18%（P = 0.006）。两组肝性脑病的发生率相似。在腹腔穿刺放液失败的患者中，10例在随机分组后平均5.5±4个月接受了经颈静脉分流术；4例对这种挽救治疗有反应。