外科分流术和经颈静脉肝内门体分流术治疗复杂门静脉高压症的结果。

Outcomes of surgical shunts and transjugular intrahepatic portasystemic stent shunts for complicated portal hypertension.

机构信息

Centre Hépato-Biliaire, Assistance Publique - Hôpitaux de Paris (AP-HP) Hôpital Paul Brousse, Villejuif, France.

Department of General Surgery, Chiba University Graduate School of Medicine, Chiba, Japan.

出版信息

Br J Surg. 2017 Mar;104(4):443-451. doi: 10.1002/bjs.10431. Epub 2017 Jan 12.

DOI:10.1002/bjs.10431

PMID:28079252

Abstract

BACKGROUND

Transjugular intrahepatic portasystemic stent shunt (TIPSS), instead of surgical shunt, has become the standard treatment for patients with complicated portal hypertension. This study compared outcomes in patients who underwent TIPSS or surgical shunting for complicated portal hypertension.

METHODS

This was a retrospective study of all consecutive patients who received portasystemic shunts from 1994 to 2014 at a single institution. Patients who underwent surgical shunting were compared with those who had a TIPSS procedure following one-to-one propensity score matching. The primary study endpoints were overall survival and shunt failure, defined as major variceal rebleeding, relapse of refractory ascites, irreversible shunt occlusion, liver failure requiring liver transplantation, or death.

RESULTS

A total of 471 patients received either a surgical shunt or TIPSS. Of these, 334 consecutive patients with cirrhosis who underwent elective surgical shunting (34) or TIPSS (300) for repeated variceal bleeding or refractory ascites were evaluated. Propensity score matching yielded 31 pairs of patients. There were no between-group differences in morbidity and 30-day mortality rates. However, shunt failure was less frequent after surgical shunting than TIPSS (6 of 31 versus 16 of 31; P = 0·016). The 5-year shunt failure-free survival (77 versus 15 per cent; P = 0·008) and overall survival (93 versus 42 per cent; P = 0·037) rates were higher for patients with surgical shunts. Multivariable analysis revealed that a Model for End-Stage Liver Disease (MELD) score exceeding14 and TIPSS were independently associated with shunt failure. In patients with MELD scores of 14 or less, the 5-year overall survival rate remained higher after surgical shunting than TIPSS (100 versus 40 per cent; P < 0·001).

CONCLUSION

Surgical shunting achieved better results than TIPSS in patients with complicated portal hypertension and low MELD scores.

摘要

背景

经颈静脉肝内门体分流术（TIPSS）已替代手术分流术，成为治疗复杂门静脉高压症的标准治疗方法。本研究比较了 TIPSS 与手术分流术治疗复杂门静脉高压症的结果。

方法

这是一项回顾性研究，纳入了 1994 年至 2014 年在单家机构接受门体分流术的所有连续患者。将接受手术分流术的患者与经倾向性评分匹配后行 TIPSS 治疗的患者进行比较。主要研究终点为总生存率和分流失败率，定义为主要静脉曲张再出血、难治性腹水复发、不可逆转的分流阻塞、需要肝移植的肝功能衰竭或死亡。

结果

共 471 例患者接受了手术分流术或 TIPSS。其中，334 例连续肝硬化患者因反复静脉曲张出血或难治性腹水而行择期手术分流（34 例）或 TIPSS（300 例），对其进行评估。倾向性评分匹配产生了 31 对患者。两组患者的发病率和 30 天死亡率无差异。然而，手术分流后的分流失败率低于 TIPSS（31 例中有 6 例 vs. 31 例中有 16 例；P=0·016）。手术分流患者的 5 年无分流失败生存率（77% vs. 15%；P=0·008）和总生存率（93% vs. 42%；P=0·037）较高。多变量分析显示，终末期肝病模型评分（MELD）超过 14 分和 TIPSS 是分流失败的独立相关因素。在 MELD 评分在 14 分或以下的患者中，手术分流后的 5 年总生存率仍高于 TIPSS（100% vs. 40%；P<0·001）。