Brown R S, Lake J R
Department of Medicine, University of California, San Francisco, School of Medicine, USA.
Adv Intern Med. 1997;42:485-504.
The TIPS clearly has had a major impact on the treatment of complications of portal hypertension in the cirrhotic patient. Currently, TIPS is performed in community hospitals as well as university centers in the United States. While the shunt is placed under local anesthesia in a nonoperative fashion, it must be remembered that it does function as a highly effective side-to-side shunt with its attendant complications including hepatic encephalopathy and occasional liver failure. Early reports of clinical and hemodynamic results after TIPS have clearly demonstrated it to be an effective bridge to liver transplantation. Nonetheless, transplantation candidates who experience their initial episode of variceal hemorrhage still should be managed with sclerotherapy or variceal band ligation. However, if bleeding recurs during a course of treatment or cannot be acutely controlled, TIPS has proved invaluable in stabilizing patients prior to liver transplantation. Refractory variceal bleeding in Child's class C patients, in whom the perioperative mortality associated with surgical shunts is high, is also reasonable indication for TIPS. Potential, but less well-proved indications for TIPS include refractory ascites, hepatic hydrothorax, and the Budd-Chiari syndrome. Refractory variceal hemorrhage in Child's class A or B patients, bleeding from portal hypertensive gastropathy, and HRS represent possible, but unproved, indications. Preoperative reduction in portal hypertension prior to liver transplantation does not appear to represent an appropriate indication for TIPS. In spite of the wide acceptance of TIPS, it will be important to continue to study its indications and its complications so that it can be optimally used in the treatment of patients with portal hypertension.
经颈静脉肝内门体分流术（TIPS）显然对肝硬化患者门静脉高压并发症的治疗产生了重大影响。目前，美国的社区医院和大学中心都在开展TIPS手术。虽然该分流术是在局部麻醉下以非手术方式进行的，但必须记住，它实际上起到了高效的侧侧分流作用，随之而来的并发症包括肝性脑病和偶尔出现的肝功能衰竭。TIPS术后早期的临床和血流动力学结果报告清楚地表明，它是肝移植的有效桥梁。尽管如此，首次发生静脉曲张出血的移植候选者仍应采用硬化疗法或静脉曲张套扎术进行治疗。然而，如果在治疗过程中出血复发或无法迅速控制，TIPS已被证明在肝移植前稳定患者病情方面具有不可估量的价值。Child C级患者的难治性静脉曲张出血，这类患者手术分流的围手术期死亡率很高，也是TIPS的合理适应证。TIPS潜在的、但证据尚不充分的适应证包括难治性腹水、肝性胸水和布加综合征。Child A级或B级患者的难治性静脉曲张出血、门静脉高压性胃病出血和肝肾综合征是可能的，但未经证实的适应证。肝移植前降低门静脉压力似乎不是TIPS的合适适应证。尽管TIPS已被广泛接受，但继续研究其适应证和并发症很重要，以便能在门静脉高压患者的治疗中得到最佳应用。
