Millis J M, Martin P, Gomes A, Shaked A, Colquhoun S D, Jurim O, Goldstein L, Busuttil R W
Department of Surgery, Dumont-UCLA Transplant Center, UCLA School of Medicine, USA.
Liver Transpl Surg. 1995 Jul;1(4):229-33. doi: 10.1002/lt.500010406.
This study was designed to evaluate the impact of transjugular intrahepatic portosystemic shunts (TIPS) on liver transplantation. Historically, the complications of portal hypertension have been temporized with sclerotherapy or surgical portosystemic shunts. In patients whose liver disease progressed, liver transplantation has been used as definitive treatment. More recently, TIPS is being used increasingly for the management of the complications of portal hypertension. The impact of this new modality on liver transplantation is evaluated. The records of 135 adult patients undergoing liver transplantation at University of California at Los Angeles between October 1992 and June 1993 were reviewed. Twenty-three patients had received at least one shunt before transplantation. The TIPS procedure complicated the operative course of 5 patients (22%). In 2 patients the TIPS had been placed cephalad, making placement of the suprahepatic vena caval clamp difficult. In 2 other patients, the shunt had been placed caudad, extending in the extrahepatic portal vein. In all 4 of these patients, the intima had been damaged at the area of the subsequent anastomosis. In the fifth patient, the bile duct had been perforated during the placement of the shunt, causing diffuse bile peritonitis, which was sterile, and the transplantation was performed. The average intraoperative blood loss for these 5 patients was 13 U. There was no significant decrease in intraoperative blood loss for all patients with a TIPS when compared with 112 adults who underwent liver transplantation during the same period (11 U v 10.5 U). The TIPS stent did not improve objective intraoperative parameters as compared with liver transplant recipients without TIPS. The indications for TIPS must be carefully weighed against the potential risks of increasing the technical difficulty of the transplantation and jeopardizing the candidacy of some liver transplantation candidates. Liver transplantation is not facilitated by TIPS insertion and therefore should not be used to justify TIPS placement.
本研究旨在评估经颈静脉肝内门体分流术（TIPS）对肝移植的影响。从历史上看，门静脉高压症的并发症一直通过硬化疗法或外科门体分流术来缓解。在肝病进展的患者中，肝移植已被用作确定性治疗方法。最近，TIPS越来越多地用于门静脉高压症并发症的管理。本研究评估了这种新方法对肝移植的影响。回顾了1992年10月至1993年6月在加利福尼亚大学洛杉矶分校接受肝移植的135例成年患者的记录。23例患者在移植前至少接受过一次分流术。TIPS手术使5例患者（22%）的手术过程变得复杂。在2例患者中，TIPS放置在头侧，导致肝上腔静脉夹的放置困难。在另外2例患者中，分流器放置在尾侧，延伸至肝外门静脉。在所有这4例患者中，后续吻合部位的内膜均受到损伤。在第5例患者中，分流器放置过程中胆管穿孔，导致弥漫性胆汁性腹膜炎（无菌性），随后进行了移植。这5例患者的术中平均失血量为13单位。与同期接受肝移植的112例成年人相比，所有接受TIPS的患者术中失血量没有显著减少（11单位对10.5单位）。与未接受TIPS的肝移植受者相比，TIPS支架并未改善客观的术中参数。必须仔细权衡TIPS的适应证与增加移植技术难度和危及一些肝移植候选者资格的潜在风险。TIPS植入并不能促进肝移植，因此不应将其用于证明TIPS放置的合理性。
