Biecker Erwin, Roth Felix, Heller Jörg, Schild Hans H, Sauerbruch Tilman, Schepke Michael
Department of Internal Medicine I, University Hospital of Bonn, University of Bonn, Sigmund-Freud-Str. 25, Bonn, Germany.
Eur J Gastroenterol Hepatol. 2007 Oct;19(10):846-52. doi: 10.1097/MEG.0b013e3282eeb488.
The aim of this study was to determine the prognostic relevance of the portal pressure gradient (PPG) before and after transjugular intrahepatic portosystemic stent shunt (TIPS) insertion in patients with liver cirrhosis and recurrent oesophageal variceal bleeding.
118 cirrhotic patients (Child A/B/C, 41/56/21; Child score, 7.7+/-2.0; baseline PPG, 21.8+/-4.7 mmHg) underwent TIPS for the prevention of variceal rebleeding. A multivariate logistic regression analysis was applied to identify the independent determinants of rebleeding and survival. The estimated rebleeding rate and the estimated survival were compared by log-rank testing.
TIPS insertion reduced the PPG by 53.2+/-17.7%. During follow-up 21 patients suffered significant rebleeding (17.8%); bleeding-related mortality was 3.4% (four patients). The median survival [95% confidence intervals (CI)] was 48.2 (39.8; 60.8) months. The multivariate Cox model identified creatinine as the only independent predictor of survival, and the initial decrease of the PPG after TIPS as the only independent predictor of rebleeding. PPG before TIPS (21.8+/-4.7 mmHg) and the gradient at the time of rebleeding (22.0+/-2.9 mmHg) did not differ significantly. Patients with an initial decrease of the PPG after TIPS <30% were at the highest risk for rebleeding. Patients with an initial decrease of the PPG >60% rarely suffered from rebleeding.
The initial decrease in the PPG after TIPS is a predictor for the risk of rebleeding but not for survival after TIPS. For that reason, in patients undergoing TIPS placement for the prevention of recurrent bleeding from oesophageal varices, an initial reduction of the PPG of 30-50% should be attempted.
本研究旨在确定经颈静脉肝内门体分流术（TIPS）植入前后门静脉压力梯度（PPG）对肝硬化伴复发性食管静脉曲张出血患者的预后相关性。
118例肝硬化患者（Child A/B/C级，分别为41/56/21例；Child评分7.7±2.0；基线PPG 21.8±4.7 mmHg）接受TIPS以预防静脉曲张再出血。采用多因素逻辑回归分析确定再出血和生存的独立决定因素。通过对数秩检验比较估计的再出血率和估计的生存率。
TIPS植入使PPG降低了53.2±17.7%。随访期间，21例患者发生严重再出血（17.8%）；出血相关死亡率为3.4%（4例患者）。中位生存期[95%置信区间（CI）]为48.2（39.8；60.8）个月。多因素Cox模型确定肌酐是生存的唯一独立预测因素，TIPS后PPG的初始下降是再出血的唯一独立预测因素。TIPS前的PPG（21.8±4.7 mmHg）与再出血时的梯度（22.0±2.9 mmHg）无显著差异。TIPS后PPG初始下降<30%的患者再出血风险最高。TIPS后PPG初始下降>60%的患者很少发生再出血。
TIPS后PPG的初始下降是再出血风险的预测因素，但不是TIPS后生存的预测因素。因此，对于接受TIPS植入以预防食管静脉曲张复发性出血的患者，应尝试使PPG初始降低30-50%。
