采用预后评分预测行挽救性 TIPS 治疗的难治性静脉曲张出血患者的中期和长期生存情况。
Intermediate and long-term survival prediction using prognostic scores in patients undergoing salvage TIPS for uncontrolled variceal bleeding.
机构信息
Surgical Gastroenterology Unit, Groote Schuur Hospital, and Department of Surgery, Faculty of Health Sciences, University of Cape Town, South Africa.
Department of Medicine, Faculty of Health Sciences, University of Cape Town, South Africa.
出版信息
S Afr J Surg. 2024 May;62(2):54-57.
BACKGROUND
This study investigated the value of prognostic scores to predict 90-day, 1-, 3- and 5-year survival after salvage TIPS (sTIPS) in patients with exsanguinating variceal bleeding who failed endoscopic intervention.
METHODS
The Model for End-Stage Liver Disease (MELD), Model for End-Stage Liver Disease Sodium (MELDNa), Acute Physiology and Chronic Health Evaluation II (APACHE II) and Child-Pugh (C-P) grades and scores were calculated using Kaplan-Meier curves and Cox proportional hazards models in sTIPS patients treated between August 1991 and November 2020.
RESULTS
Thirty-four patients (29 men, 5 women), mean age 52 years, SD ± 11.6 underwent sTIPS which controlled bleeding in 32 (94%) patients. Ten (29.4%) patients died in hospital at a median of 4.8 (range 1-10) days. On bivariate analysis, C-P score ≥ 10 ( = 0.017), high C-P grade ( = 0.048), MELD ≥ 15 ( = 0.010), MELD-Na score ≥ 22 ( < 0.001) and APACHE II score ≥ 15 ( < 0.001) predicted 90-day mortality. Individual clinical characteristics associated with 90-day mortality were grade 3 ascites ( = 0.029), > 10 units of blood transfused ( = 0.004), balloon tube placement ( < 0.001), endotracheal intubation (< 0.001) and inotrope support ( < 0.001). The overall 90-day, 1-, 3- and 5-year survival rates were 67.6%, 55.9%, 26.5% and 20.6% respectively. Nine patients (26.5%) were alive at a median of two years (range 1-18 years) post-TIPS. Patients with C-P grade A, C-P score < 10, MELD score < 15, MELD-Na score < 22 and APACHE II score < 15 had significantly better 90-day, 1-, 3- and 5-year survival rates.
CONCLUSION
Although sTIPS controlled variceal bleeding in 94% of patients after failed endoscopic therapy, in-hospital mortality was 29% and less than one quarter were alive after five years. The selected cut-off values for the nominated scoring systems accurately predicted 90-day mortality and long-term survival.
背景
本研究旨在探讨预后评分在预测内镜治疗失败的出血性静脉曲张患者行挽救性经颈静脉肝内门体分流术（sTIPS）后 90 天、1 年、3 年和 5 年生存的价值。
方法
使用 Kaplan-Meier 曲线和 Cox 比例风险模型计算终末期肝病模型（MELD）、终末期肝病钠模型（MELDNa）、急性生理学和慢性健康评估 II（APACHE II）和 Child-Pugh（C-P）评分和等级，这些评分和等级在 1991 年 8 月至 2020 年 11 月期间接受 sTIPS 治疗的患者中进行计算。
结果
34 名患者（29 名男性，5 名女性），平均年龄 52 岁，标准差 ± 11.6 岁，接受 sTIPS 治疗，其中 32 名（94%）患者出血得到控制。10 名（29.4%）患者在中位 4.8 天（范围 1-10）内死于院内。在单变量分析中，C-P 评分≥10（=0.017）、高 C-P 等级（=0.048）、MELD≥15（=0.010）、MELD-Na 评分≥22（<0.001）和 APACHE II 评分≥15（<0.001）预测 90 天死亡率。与 90 天死亡率相关的个体临床特征包括 3 级腹水（=0.029）、>10 单位输血（=0.004）、球囊管放置（<0.001）、气管插管（<0.001）和儿茶酚胺支持（<0.001）。总体 90 天、1 年、3 年和 5 年生存率分别为 67.6%、55.9%、26.5%和 20.6%。9 名患者（26.5%）在 TIPS 后中位时间 2 年（范围 1-18 年）时存活。C-P 分级 A、C-P 评分<10、MELD 评分<15、MELD-Na 评分<22 和 APACHE II 评分<15 的患者 90 天、1 年、3 年和 5 年生存率显著提高。
结论
尽管 sTIPS 控制了内镜治疗失败后 94%的静脉曲张出血，但院内死亡率为 29%，五年后不到四分之一的患者存活。提名评分系统的选定截断值可准确预测 90 天死亡率和长期生存率。
Zotero 插件