Sanyal A J, Freedman A M, Luketic V A, Purdum P P, Shiffman M L, Tisnado J, Cole P E
Division of Gastroenterology, Medical College of Virginia, Virginia Commonwealth University, Richmond, USA.
Gastroenterology. 1996 Jul;111(1):138-46. doi: 10.1053/gast.1996.v111.pm8698192.
BACKGROUND & AIMS: Despite urgent sclerotherapy, active variceal hemorrhage has a 70%-90% mortality rate in patients with advanced age, sepsis, renal or pulmonary compromise, tense ascites, or deep coma. The aim of this study was to test the safety and efficacy of transjugular intrahepatic portosystemic shunt (TIPS) performed semiemergently and preceded by stabilization by balloon tamponade in such patients.
Patients with actively bleeding esophageal or contiguous gastric varices despite sclerotherapy were assessed for risk of dying after emergent portacaval shunt. Those considered to be at high risk were stabilized by balloon tamponade and vasopressin/nitroglycerin and TIPS placed semiurgently within 12 hours. Balloon tamponade and pharmacological therapy were discontinued within 24 hours after TIPS in all cases.
Thirty-two patients met entry criteria, and 2 were excluded due to portal vein thrombosis. TIPS was successfully placed in 29 of 30 patients and achieved hemostasis in all. Thirty-day and 6-week survival rates were 63% and 60%, respectively; in those without aspiration, the 6-week survival rate was 90%. After a median follow-up period of 920 days, 46% of the original cohort was alive. Only 2 episodes of early rebleeding and 4 late rebleeds occurred. Eight patients developed encephalopathy. Stent stenosis requiring dilation occurred in 6 of 11 patients within 6 months.
TIPS is highly effective as salvage therapy in high-risk patients with active variceal hemorrhage despite endoscopic sclerotherapy.
尽管进行了紧急硬化治疗，但在高龄、脓毒症、肾或肺功能不全、大量腹水或深度昏迷的患者中，活动性静脉曲张出血的死亡率仍为70%-90%。本研究的目的是检验在这类患者中，先通过球囊压迫进行稳定治疗，然后半紧急进行经颈静脉肝内门体分流术（TIPS）的安全性和有效性。
对尽管接受了硬化治疗但仍有活动性食管或相邻胃静脉曲张出血的患者，评估其在急诊门腔分流术后的死亡风险。那些被认为高危的患者通过球囊压迫和血管加压素/硝酸甘油进行稳定治疗，并在12小时内半紧急进行TIPS。所有病例在TIPS术后24小时内停止球囊压迫和药物治疗。
32例患者符合入选标准，2例因门静脉血栓形成被排除。30例患者中的29例成功置入TIPS，所有患者均实现止血。30天和6周生存率分别为63%和60%；在无吸入性肺炎的患者中，6周生存率为90%。中位随访期920天后，原队列中有46%存活。仅发生2例早期再出血和4例晚期再出血。8例患者发生脑病。11例患者中有6例在6个月内出现需要扩张的支架狭窄。
对于尽管接受了内镜硬化治疗但仍有活动性静脉曲张出血的高危患者，TIPS作为挽救治疗非常有效。
