Jalan R, Harrison D J, Redhead D N, Hayes P C
Centre for Liver and Digestive Disorders, Department of Medicine, Edinburgh, UK.
J Hepatol. 1996 Feb;24(2):169-76. doi: 10.1016/s0168-8278(96)80026-2.
BACKGROUND/AIM: The aim of this study was to assess the pathology and pathogenic mechanisms involved in the occlusion of transjugular intrahepatic portosystemic stent-shunts.
Thirty-four patients with transjugular intrahepatic portosystemic stent-shunt who had at least two portographic assessments of shunt function were the subjects of this study. The contents of any shunt demonstrating > 70% stenosis were biopsied before balloon dilatation. Further assessment was made of 10 livers obtained at either post mortem (8) or at liver transplantation (2). Cholangiography was performed in these explanted livers, which were then perfused and fixed with formaldehyde. The shunts were dissected out, sectioned, opened and the contents and the surrounding liver examined macroscopically, histopathologically and immunohistochemically.
Fourteen patients with TIPSS developed shunt stenosis. In eight patients the stenosis was greater than 70% and significant re-stenosis occurred in all at repeat portography. Three of these patients who were managed by insertion of new shunts showed no further shunt-related problems, whereas the five who were treated solely by dilatation developed further re-stenosis. Organising thrombus was found in all eight patients and bile was incorporated in the thrombus in four. Biliary epithelium was found in two. Four of the ten explanted livers showed evidence of shunt stenosis, of which three were severe and one was mild (< 70%). The occluding material in patients with severe stenosis was composed of organising thrombus containing bile and a granulomatous inflammatory response. This was associated with a transected bile duct, and the degree of stenosis was related closely to the size of the bile duct transected. The shunts free of bile showed no stenosis.
The results of this study suggest that transection of a major bile duct and bile leak play an important role in the stenosis and occlusion of the intraparenchymal portion of transjugular intrahepatic portosystemic stent-shunt. This has important implications for patient management and stent design.
背景/目的：本研究旨在评估经颈静脉肝内门体分流术（TIPSS）支架闭塞所涉及的病理及发病机制。
本研究以34例行TIPSS且至少接受过两次分流功能门静脉造影评估的患者为研究对象。对任何狭窄程度>70%的分流通道在球囊扩张术前进行活检。对另外10例通过尸检（8例）或肝移植（2例）获得的肝脏进行进一步评估。对这些切除的肝脏进行胆管造影，然后用甲醛灌注并固定。将分流通道取出、切片、打开，对其内容物及周围肝脏进行大体、组织病理学及免疫组织化学检查。
14例TIPSS患者出现分流通道狭窄。8例患者狭窄程度大于70%，再次门静脉造影时所有患者均出现明显再狭窄。其中3例通过植入新的分流通道治疗的患者未再出现与分流通道相关的问题，而另外5例仅接受扩张治疗的患者出现了进一步的再狭窄。所有8例患者均发现有组织化血栓，4例患者的血栓中包含胆汁。2例患者发现有胆管上皮。10例切除的肝脏中有4例显示存在分流通道狭窄，其中3例严重，1例轻度（<70%）。重度狭窄患者的闭塞物质由含有胆汁的组织化血栓和肉芽肿性炎症反应组成。这与一条横断的胆管相关，狭窄程度与横断胆管的大小密切相关。无胆汁的分流通道未出现狭窄。
本研究结果提示，主要胆管的横断及胆汁漏在经颈静脉肝内门体分流术肝实质内部分的狭窄和闭塞中起重要作用。这对患者管理及支架设计具有重要意义。
