Ochs A, Rössle M, Haag K, Hauenstein K H, Deibert P, Siegerstetter V, Huonker M, Langer M, Blum H E
Department of Medicine, Albert Ludwig University School of Medicine, Freiburg, Germany.
N Engl J Med. 1995 May 4;332(18):1192-7. doi: 10.1056/NEJM199505043321803.
Previous studies have suggested that the transjugular placement of an intrahepatic stent to establish a portosystemic shunt is an effective treatment of uncomplicated ascites accompanying variceal bleeding. We studied the stent shunt for use in patients with liver cirrhosis and ascites refractory to medical treatment.
Fifty of 62 consecutive patients with cirrhosis and refractory ascites (18 with Child-Pugh class B liver disease and 32 with class C) were treated with the stent shunt--an expandable stent of metallic mesh placed between a major branch of the portal vein and one of the hepatic veins. Patients were followed for a mean (+/- SD) of 426 +/- 333 days. Those with advanced cancer, severe heart failure, or severe liver failure were excluded.
The stent shunt was successfully placed in all patients and reduced the pressure gradient between the portal vein and the inferior vena cava by an average of 63 percent. Thirty-seven patients (74 percent) had complete responses (total remission of ascites within three months), and nine patients (18 percent) had partial responses (ascites detected by ultrasound but with no need for paracentesis). Four patients did not respond, including two who died within two weeks of shunt placement. After the procedure, 25 patients had hepatic encephalopathy, as compared with 20 patients before the procedure; although encephalopathy improved in 3 patients, new encephalopathy developed in 8 patients. In the 28 of the 33 patients followed for more than six months who were evaluated, the mean serum creatinine concentration was 1.5 +/- 0.09 mg per deciliter (133 +/- 8 mumol per liter) before placement of the stent shunt, 1.5 +/- 1.6 mg per deciliter (133 +/- 141 mumol per liter) one week after the procedure, and 0.9 +/- 0.3 mg per deciliter (80 +/- 27 mumol per liter) after six months (P = 0.008 for the comparison of concentrations before and six months after the procedure). Renal function did not improve in the six patients with organic kidney disease. Procedure-related complications developed in 16 patients, including intraabdominal bleeding requiring blood transfusions in 2 patients. Thrombotic occlusion of the stent shunt occurred within two weeks in 5 patients, and later insufficiency of the shunt occurred in 16 patients, including 12 with recurrence of ascites after complete remission. During followup, an additional 29 patients died--10 of progressive liver disease and 19 of other causes. Survival for at least one year was associated with a patient's being under 60 years of age, having a serum bilirubin level before placement of the stent shunt of less than 1.3 mg per deciliter (22 mumol per liter), and having a complete response.
Our findings in an uncontrolled prospective study suggest that the transjugular intrahepatic porto-systemic stent-shunt procedure was an effective treatment for many patients with liver cirrhosis and refractory ascites, but mortality from underlying diseases was substantial.
先前的研究表明，经颈静脉放置肝内支架以建立门体分流是治疗伴有静脉曲张出血的单纯性腹水的有效方法。我们研究了支架分流术在肝硬化和药物治疗无效的腹水患者中的应用。
62例连续的肝硬化和难治性腹水患者（18例Child-Pugh B级肝病患者和32例C级患者）中的50例接受了支架分流术，即一种金属网状可扩张支架置于门静脉的一个主要分支与一条肝静脉之间。患者平均随访（±标准差）426±333天。排除患有晚期癌症、严重心力衰竭或严重肝功能衰竭的患者。
所有患者均成功放置支架分流器，门静脉与下腔静脉之间的压力梯度平均降低63%。37例患者（74%）完全缓解（三个月内腹水完全消退），9例患者（18%）部分缓解（超声检测到腹水但无需腹腔穿刺）。4例患者无反应，包括2例在分流术后两周内死亡。术后25例患者发生肝性脑病，术前为20例；虽然3例患者的脑病有所改善，但8例患者出现了新的脑病。在随访超过6个月的33例患者中，28例接受了评估，支架分流术前平均血清肌酐浓度为1.5±0.09mg/dl（133±8μmol/L），术后1周为1.5±1.6mg/dl（133±141μmol/L），6个月后为0.9±（0.3mg/dl）（80±27μmol/L）（术前与术后6个月浓度比较，P = 0.008）。6例患有器质性肾病的患者肾功能未改善。16例患者出现与手术相关的并发症，包括2例需要输血治疗腹腔内出血。5例患者在两周内发生支架分流器血栓闭塞，16例患者后来出现分流不足，包括12例在完全缓解后腹水复发。随访期间，另有29例患者死亡，10例死于进行性肝病，19例死于其他原因。至少存活一年与患者年龄小于60岁、支架分流术前血清胆红素水平低于1.3mg/dl（22μmol/L）以及完全缓解相关。
我们在一项非对照前瞻性研究中的发现表明，经颈静脉肝内门体支架分流术对许多肝硬化和难治性腹水患者是一种有效的治疗方法，但潜在疾病导致的死亡率很高。
