Iannone Giulia, Pompili Enrico, De Venuto Clara, Pratelli Dario, Tedesco Greta, Baldassarre Maurizio, Caraceni Paolo, Zaccherini Giacomo
Department of Medical and Surgical Sciences, University of Bologna, 40138 Bologna, Italy.
Unit of Semeiotics, Liver and Alcohol-Related Diseases, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy.
J Clin Med. 2024 Feb 27;13(5):1349. doi: 10.3390/jcm13051349.
The development and progression of ascites represent a crucial event in the natural history of patients with cirrhosis, predisposing them to other complications and carrying a heavy impact on prognosis. The current standard of care for the management of ascites relies on various combinations of diuretics and large-volume paracenteses. Periodic long-term albumin infusions on top of diuretics have been recently shown to greatly facilitate the management of ascites. The insertion of a transjugular intrahepatic portosystemic shunt (TIPS), an artificial connection between the portal and caval systems, is indicated to treat patients with refractory ascites. TIPS acts to decrease portal hypertension, thus targeting an upstream event in the pathophysiological cascade of cirrhosis decompensation. Available evidence shows a significant benefit on ascites control/resolution, with less clear results on patient survival. Patient selection plays a crucial role in obtaining better clinical responses and avoiding TIPS-related adverse events, the most important of which are hepatic encephalopathy, cardiac overload and failure, and liver failure. At the same time, some recent technical evolutions of available stents appear promising but deserve further investigations. Future challenges and perspectives include (i) identifying the features for selecting the ideal candidate to TIPS; (ii) recognizing the better timing for TIPS placement; and (iii) understanding the most appropriate role of TIPS within the framework of all other available treatments for the management of patients with decompensated cirrhosis.
腹水的发生和进展是肝硬化患者自然病程中的关键事件，使其易发生其他并发症，并对预后产生重大影响。目前腹水管理的标准治疗方法依赖于利尿剂和大量腹腔穿刺放液的各种联合应用。最近研究表明，在使用利尿剂的基础上定期长期输注白蛋白可极大地促进腹水的管理。经颈静脉肝内门体分流术（TIPS）是门静脉和腔静脉系统之间的人工连接，用于治疗难治性腹水患者。TIPS的作用是降低门静脉高压，从而针对肝硬化失代偿病理生理级联反应中的上游事件。现有证据表明，TIPS对腹水控制/消退有显著益处，但对患者生存的影响尚不清楚。患者选择在获得更好的临床反应和避免TIPS相关不良事件方面起着关键作用，其中最重要的是肝性脑病、心脏超负荷和衰竭以及肝功能衰竭。同时，现有支架的一些最新技术进展似乎很有前景，但值得进一步研究。未来的挑战和前景包括：（i）确定选择TIPS理想候选者的特征；（ii）识别TIPS置入的最佳时机；（iii）在失代偿期肝硬化患者所有其他可用治疗方法的框架内，理解TIPS最合适的作用。
