Kim John J, Dasika Narasimham L, Yu Esther, Fontana Robert J
Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA.
J Clin Gastroenterol. 2009 Jul;43(6):574-9. doi: 10.1097/MCG.0b013e31818738ef.
A transjugular intrahepatic portosystemic shunt (TIPS) can potentially reduce the risk of perioperative complications in cirrhotic patients undergoing surgery but experience is limited. The aim of our study was to assess the clinical outcomes in consecutive cirrhotic patients with a patent TIPS undergoing major extrahepatic surgery.
Between July 1992 and January 2007, 25 cirrhotic patients with a patent TIPS underwent abdominal or cardiothoracic surgery at a single center. Preoperative laboratory and clinical features and postoperative outcomes were reviewed.
Mean subject age was 49+/-12 years. The TIPS was placed at a median of 20 days before surgery (range, 1 to 2338 d). In 19 patients, the TIPS had been previously placed for management of refractory ascites or bleeding varices whereas in 6 patients, the TIPS was specifically placed for portal decompression before planned surgery. The mean hepatic venous pressure gradient was significantly reduced from 19.6+/-5.5 to 8.7+/-2.9 mm Hg post-TIPS (P<0.001). The mean preoperative Model for End Stage Liver Disease (MELD) score was 15+/-7.6 and Child-Turcotte-Pugh scores were A (8%), B (64%), and C (28%). Nineteen abdominal and 6 cardiothoracic surgeries were performed under emergent (32%) or urgent (24%) circumstances. Postoperatively, severe ascites developed in 29% and encephalopathy in 17%. The median postoperative intensive care unit and hospital stay were 1 day (range, 0 to 26 d) and 7 days (0 to 32 d), respectively. During a median follow-up of 33 months, actuarial 1-year patient survival was 74%. The 3 patients (12%) who died during their hospitalization all had MELD scores > or = 25 and required emergency surgery.
Portal decompression via TIPS may allow selected cirrhotic patients to safely undergo major surgery with an acceptable rate of short-term morbidity and mortality.
经颈静脉肝内门体分流术（TIPS）可能会降低肝硬化患者手术围手术期并发症的风险，但相关经验有限。我们研究的目的是评估连续行TIPS且分流道通畅的肝硬化患者接受肝外大手术的临床结局。
1992年7月至2007年1月期间，25例TIPS分流道通畅的肝硬化患者在单一中心接受了腹部或心胸外科手术。回顾术前实验室检查和临床特征以及术后结局。
患者平均年龄为49±12岁。TIPS在手术前的中位时间为20天（范围1至2338天）。19例患者先前放置TIPS是为了治疗难治性腹水或静脉曲张破裂出血，而6例患者是在计划手术前专门为了门静脉减压而放置TIPS。TIPS术后肝静脉压力梯度从19.6±5.5显著降至8.7±2.9 mmHg（P<0.001）。术前终末期肝病模型（MELD）评分平均为15±7.6，Child-Turcotte-Pugh评分A级占8%，B级占64%，C级占28%。19例腹部手术和6例心胸手术是在急诊（32%）或紧急（24%）情况下进行的。术后，29%的患者出现严重腹水，17%的患者出现肝性脑病。术后重症监护病房（ICU）住院时间和住院时间的中位数分别为1天（范围0至26天）和7天（0至32天）。在中位随访33个月期间，1年预期患者生存率为74%。住院期间死亡的3例患者（12%）MELD评分均≥25分且需要急诊手术。
通过TIPS进行门静脉减压可能使部分肝硬化患者安全地接受大手术，且短期发病率和死亡率在可接受范围内。
