目的观察肝侧门静脉一肝总动脉侧端分流术和侧侧分流术（统称门肝分流术）对猪肝硬化门脉高压症动物模型的治疗效果。方法对照组和实验组（即肝硬化门脉高压模型组）实验猪各15头分别行门肝分流术，观察门静脉血入肝及降压的过程。结果...目的观察肝侧门静脉一肝总动脉侧端分流术和侧侧分流术（统称门肝分流术）对猪肝硬化门脉高压症动物模型的治疗效果。方法对照组和实验组（即肝硬化门脉高压模型组）实验猪各15头分别行门肝分流术，观察门静脉血入肝及降压的过程。结果对照组和实验组门肝分流术前门静脉压力分别为（20．51±0．74）cmH2O（1 cm H2O=0．098kPa）和（30．82±2．53）cmH2O（P〈0．05）；术后30d分别为（19．75±0．84）cmH2O和（20．84±1．36）cmH2O（P〉0．05）。对照组和实验组门静脉与肝总动脉的压力差术前分别为（7．20±0．34）cmH2O和（17．34±0．62）cmH2O（P〈0．05）；术后30d分别为（6．40±0．21）cmH2O和（7．84±1．32）cmH2O（P〉0．05）。分流后术中脾静脉注射亚甲蓝肝脏染色良好。术后观察30d无肝坏死及肝性脑病发生，脾肿大恢复正常。门肝分流术对肝功能的影响较大，对其他血生化代谢指标影响较小。结论门肝分流术后虽然门静脉血入肝通道发生变更，但门脉血流动力学并未受到显著影响，反而建立了新的平衡机制来维持门脉血流动力学的稳定，达到门脉降压效果。门肝分流术后肝功能恢复所需时间较长，且需进一步治疗。展开更多
AIM： To evaluate the efficacy of transjugular intrahepatic portosystemic shunts （TIPSs） after liver transplantation （LT）. METHODS： Between November 1996 and December 2005, 10 patients with severe recurrent hepat...AIM： To evaluate the efficacy of transjugular intrahepatic portosystemic shunts （TIPSs） after liver transplantation （LT）. METHODS： Between November 1996 and December 2005, 10 patients with severe recurrent hepatitis C virus infection （n = 4）, ductopenic rejection （n = 5） or portal vein thrombosis （n = 1） were included in this analysis. Eleven TIPSs （one patient underwent two TIPS procedures） were placed for management of therapy-refractory ascites （n = 7）, hydrothorax （n = 2） or bleeding from colonic varices （n = 1）. The median time interval between LT and TIPS placement was 15 （4-158） mo. RESULTS： TIPS placement was successful in all patients. The mean portosystemic pressure gradient was reduced from 12.5 to 8.7 mmHg. Complete and partial remission could be achieved in 43% and 29% of patients with ascites. Both patients with hydrothorax did not respond to TIPS. No recurrent bleeding was seen in the patient with colonic varices. Nine of 10 patients died during the study period. Only one of two patients, who underwent retransplantation after the TIPS procedure, survived. The median survival period after TIPS placement was 3.3 （range 0.4-20） too. The majority of patients died from sepsis with multiorgan failure. CONCLUSION： Indications for TIPS and technical performance in LT patients correspond to those in non-transplanted patients. At least partial control of therapy-refractory ascites and variceal bleeding could be achieved in most patients. Nevertheless, survival rates were disappointing, most probably because of the advanced stages of liver disease at the time of TIPS placement and the high risk of sepsis as a consequence of immunosuppression.展开更多
Mansonic schistosomiasis is the main cause of portal hypertension in Brazil. Hepatosplenic (HS) form is manifested by hepatomegaly mainly on the left hepatic lobe associated with large splenomegaly and bleeding due to...Mansonic schistosomiasis is the main cause of portal hypertension in Brazil. Hepatosplenic (HS) form is manifested by hepatomegaly mainly on the left hepatic lobe associated with large splenomegaly and bleeding due to esophageal varices with high mortality rates.展开更多
Background:The effect of transjugular intra-hepatic portosystemic shunt(TIPS)placement on renal function and the correlation of post-TIPS Cr with mortality remain unclear.This study aimed to assess the effect of TIPS ...Background:The effect of transjugular intra-hepatic portosystemic shunt(TIPS)placement on renal function and the correlation of post-TIPS Cr with mortality remain unclear.This study aimed to assess the effect of TIPS placement on renal function and to examine the relationship between post-TIPS Cr and mortality risk.Methods:A total of 593 patients who underwent de novo TIPS placement between 2004 and 2017 at a single institution were included in the study.The pre-TIPS Cr level(T0;within 7 days before TIPS placement)and post-TIPS Cr levels,at 1–2 days(T1),5–12 days(T2),and 15–40 days(T3),were collected.Predictors of Cr change after TIPS placement and the 1-year mortality rate were analysed using multivariable linear-regression and Cox proportional-hazards models,respectively.Results:Overall,21.4%of patients(n=127)had elevated baseline Cr(≤1.5 mg/dL;mean,2.5161.49 mg/dL)and 78.6%(n=466)had normal baseline Cr(<1.5 mg/dL;mean,0.9260.26 mg/dL).Patients with elevated pre-TIPS Cr demonstrated a decrease in post-TIPS Cr(difference,-0.60 mg/dL),whereas patients with normal baseline Cr exhibited no change(difference,<0.01 mg/dL).The 30-day,90-day,and 1-year mortality rates were 13%,20%,and 32%,respectively.Variceal bleeding as a TIPS-placement indication(hazard ratio=1.731;P=0.036),higher T0 Cr(hazard ratio=1.834;P=0.012),and higher T3 Cr(hazard ratio=3.524;P<0.001)were associated with higher 1-year mortality risk.Conclusion:TIPS placement improved renal function in patients with baseline renal dysfunction and the post-TIPS Cr level was a strong predictor of 1-year mortality risk.展开更多
Portal vein thrombosis(PVT)is frequent in patients with liver cirrhosis and possible severe complications such as mesenteric ischemia are rare,but can be life-threatening.However,different aspects of clinical relevanc...Portal vein thrombosis(PVT)is frequent in patients with liver cirrhosis and possible severe complications such as mesenteric ischemia are rare,but can be life-threatening.However,different aspects of clinical relevance,diagnosis and management of PVT are still areas of uncertainty and investigation in international guidelines.In this article,we elaborate on PVT classification,geographical differences in clinical presentation and standards of diagnosis,and briefly on the current pathophysiological understanding and risk factors.This review considers and highlights the pitfalls of the various treatment approaches and prophylactic treatments.Finally,we review the controversial issue of clinical impact of PVT on prognosis,especially considering liver transplantation and future perspectives.展开更多
Variceal bleeding is one of the major causes of death in cirrhotic patients.The management during the acute phase and the secondary prophylaxis is well defined.Recent recommendations(2015 Baveno VI expert consensus)ar...Variceal bleeding is one of the major causes of death in cirrhotic patients.The management during the acute phase and the secondary prophylaxis is well defined.Recent recommendations(2015 Baveno VI expert consensus)are available and should be followed for an optimal management,which must be performed as an emergency in a liver or general intensive-care unit.It is based on the early administration of a vasoactive drug(before endoscopy),an antibiotic prophylaxis and a restrictive transfusion strategy(hemoglobin target of 7 g/dL).The endoscopic treatment is based on band ligations.Sclerotherapy should be abandoned.In the most severe patients(Child Pugh C or B with active bleeding during initial endoscopy),transjugular intrahepatic portosystemic shunt(TIPS)should be performed within 72 hours after admission to minimize the risk of rebleeding.Secondary prophylaxis is based on the association of non-selective beta-blockers(NSBBs)and repeated band ligations.TIPS should be considered when bleeding reoccurs in spite of a well-conducted secondary prophylaxis or when NSBBs are poorly tolerated.It should also be considered when bleeding is refractory.Liver transplantation should be discussed when bleeding is not controlled after TIPS insertion and in all cases when liver function is deteriorated.展开更多
Objective.Portal pressure gradient(PPG)after transjugular intrahepatic portosystemic shunt(TIPS)<12mmHg has been reported as the only factor predictive of increase in platelet count.As flow velocities measured on D...Objective.Portal pressure gradient(PPG)after transjugular intrahepatic portosystemic shunt(TIPS)<12mmHg has been reported as the only factor predictive of increase in platelet count.As flow velocities measured on Doppler ultrasound are related to pressure gradient based on the Bernoulli equation,we used this parameter to predict increased platelet count after TIPS placement.Methods.A total of 161 consecutive patients who underwent TIPS placement entered this retrospective study.The platelet count was measured before,one week after and one month after TIPS placement.Clinically significant thrombocytopenia was defined as platelet count≤100000.Pre-and post-TIPS PPGs were measured.The velocity of blood flow in the proximal,mid and distal TIPS stent was measured using Doppler ultrasound,and the difference in the highest and lowest measured velocity was entitled flow velocity gradient(FVG),which was considered normal when≤100 cm/s.Results.In 121 patients with pre-TIPS thrombocytopenia,the mean platelet count one week and one month after TIPS placement increased 25.7×10^(3) and 35.0 × 10^(3) in 90 patients with PPG≤12mmHg(P=0.028 and P=0.015),while there was no significant change in platelet count in patients with a PPG>12mmHg(P=0.098 and P=0.075).Platelets increased significantly when FVG≤100 cm/s(n=95)vs FVG>100 cm/s(n=26)one week(37.0×10^(3) vs 11.0×10^(3);P=0.005 vs 0.07)and one month after TIPS placement(17.0×10^(3) vs 5.2×10^(3);P=0.01 vs 0.21).Conclusion.FVG>100 cm/s is not associated with increase in post-TIPS platelet count.On the other hand,findings suggestive of proper TIPS function(FVG≤100 cm/s and PPG≤12mmHg)predict a significant increase in post-TIPS platelet count.展开更多
文摘目的观察肝侧门静脉一肝总动脉侧端分流术和侧侧分流术（统称门肝分流术）对猪肝硬化门脉高压症动物模型的治疗效果。方法对照组和实验组（即肝硬化门脉高压模型组）实验猪各15头分别行门肝分流术，观察门静脉血入肝及降压的过程。结果对照组和实验组门肝分流术前门静脉压力分别为（20．51±0．74）cmH2O（1 cm H2O=0．098kPa）和（30．82±2．53）cmH2O（P〈0．05）；术后30d分别为（19．75±0．84）cmH2O和（20．84±1．36）cmH2O（P〉0．05）。对照组和实验组门静脉与肝总动脉的压力差术前分别为（7．20±0．34）cmH2O和（17．34±0．62）cmH2O（P〈0．05）；术后30d分别为（6．40±0．21）cmH2O和（7．84±1．32）cmH2O（P〉0．05）。分流后术中脾静脉注射亚甲蓝肝脏染色良好。术后观察30d无肝坏死及肝性脑病发生，脾肿大恢复正常。门肝分流术对肝功能的影响较大，对其他血生化代谢指标影响较小。结论门肝分流术后虽然门静脉血入肝通道发生变更，但门脉血流动力学并未受到显著影响，反而建立了新的平衡机制来维持门脉血流动力学的稳定，达到门脉降压效果。门肝分流术后肝功能恢复所需时间较长，且需进一步治疗。
基金Supported by "Verein zur Frderung der Forschung in Gastroenterologie und Hepatologie an der Medizinischen Universitt Innsbruck"
文摘AIM： To evaluate the efficacy of transjugular intrahepatic portosystemic shunts （TIPSs） after liver transplantation （LT）. METHODS： Between November 1996 and December 2005, 10 patients with severe recurrent hepatitis C virus infection （n = 4）, ductopenic rejection （n = 5） or portal vein thrombosis （n = 1） were included in this analysis. Eleven TIPSs （one patient underwent two TIPS procedures） were placed for management of therapy-refractory ascites （n = 7）, hydrothorax （n = 2） or bleeding from colonic varices （n = 1）. The median time interval between LT and TIPS placement was 15 （4-158） mo. RESULTS： TIPS placement was successful in all patients. The mean portosystemic pressure gradient was reduced from 12.5 to 8.7 mmHg. Complete and partial remission could be achieved in 43% and 29% of patients with ascites. Both patients with hydrothorax did not respond to TIPS. No recurrent bleeding was seen in the patient with colonic varices. Nine of 10 patients died during the study period. Only one of two patients, who underwent retransplantation after the TIPS procedure, survived. The median survival period after TIPS placement was 3.3 （range 0.4-20） too. The majority of patients died from sepsis with multiorgan failure. CONCLUSION： Indications for TIPS and technical performance in LT patients correspond to those in non-transplanted patients. At least partial control of therapy-refractory ascites and variceal bleeding could be achieved in most patients. Nevertheless, survival rates were disappointing, most probably because of the advanced stages of liver disease at the time of TIPS placement and the high risk of sepsis as a consequence of immunosuppression.
文摘Mansonic schistosomiasis is the main cause of portal hypertension in Brazil. Hepatosplenic (HS) form is manifested by hepatomegaly mainly on the left hepatic lobe associated with large splenomegaly and bleeding due to esophageal varices with high mortality rates.
文摘Background:The effect of transjugular intra-hepatic portosystemic shunt(TIPS)placement on renal function and the correlation of post-TIPS Cr with mortality remain unclear.This study aimed to assess the effect of TIPS placement on renal function and to examine the relationship between post-TIPS Cr and mortality risk.Methods:A total of 593 patients who underwent de novo TIPS placement between 2004 and 2017 at a single institution were included in the study.The pre-TIPS Cr level(T0;within 7 days before TIPS placement)and post-TIPS Cr levels,at 1–2 days(T1),5–12 days(T2),and 15–40 days(T3),were collected.Predictors of Cr change after TIPS placement and the 1-year mortality rate were analysed using multivariable linear-regression and Cox proportional-hazards models,respectively.Results:Overall,21.4%of patients(n=127)had elevated baseline Cr(≤1.5 mg/dL;mean,2.5161.49 mg/dL)and 78.6%(n=466)had normal baseline Cr(<1.5 mg/dL;mean,0.9260.26 mg/dL).Patients with elevated pre-TIPS Cr demonstrated a decrease in post-TIPS Cr(difference,-0.60 mg/dL),whereas patients with normal baseline Cr exhibited no change(difference,<0.01 mg/dL).The 30-day,90-day,and 1-year mortality rates were 13%,20%,and 32%,respectively.Variceal bleeding as a TIPS-placement indication(hazard ratio=1.731;P=0.036),higher T0 Cr(hazard ratio=1.834;P=0.012),and higher T3 Cr(hazard ratio=3.524;P<0.001)were associated with higher 1-year mortality risk.Conclusion:TIPS placement improved renal function in patients with baseline renal dysfunction and the post-TIPS Cr level was a strong predictor of 1-year mortality risk.
基金We thank Sabine Dentler for English proofreading and editing.Andrea De Gottardi is supported by the Swiss National Science Foundation(Grant 31003A_163143)Jonel Trebicka is supported by DFG(SFB TRR 57,P18)and Cellex-Foundation.
文摘Portal vein thrombosis(PVT)is frequent in patients with liver cirrhosis and possible severe complications such as mesenteric ischemia are rare,but can be life-threatening.However,different aspects of clinical relevance,diagnosis and management of PVT are still areas of uncertainty and investigation in international guidelines.In this article,we elaborate on PVT classification,geographical differences in clinical presentation and standards of diagnosis,and briefly on the current pathophysiological understanding and risk factors.This review considers and highlights the pitfalls of the various treatment approaches and prophylactic treatments.Finally,we review the controversial issue of clinical impact of PVT on prognosis,especially considering liver transplantation and future perspectives.
文摘Variceal bleeding is one of the major causes of death in cirrhotic patients.The management during the acute phase and the secondary prophylaxis is well defined.Recent recommendations(2015 Baveno VI expert consensus)are available and should be followed for an optimal management,which must be performed as an emergency in a liver or general intensive-care unit.It is based on the early administration of a vasoactive drug(before endoscopy),an antibiotic prophylaxis and a restrictive transfusion strategy(hemoglobin target of 7 g/dL).The endoscopic treatment is based on band ligations.Sclerotherapy should be abandoned.In the most severe patients(Child Pugh C or B with active bleeding during initial endoscopy),transjugular intrahepatic portosystemic shunt(TIPS)should be performed within 72 hours after admission to minimize the risk of rebleeding.Secondary prophylaxis is based on the association of non-selective beta-blockers(NSBBs)and repeated band ligations.TIPS should be considered when bleeding reoccurs in spite of a well-conducted secondary prophylaxis or when NSBBs are poorly tolerated.It should also be considered when bleeding is refractory.Liver transplantation should be discussed when bleeding is not controlled after TIPS insertion and in all cases when liver function is deteriorated.
文摘Objective.Portal pressure gradient(PPG)after transjugular intrahepatic portosystemic shunt(TIPS)<12mmHg has been reported as the only factor predictive of increase in platelet count.As flow velocities measured on Doppler ultrasound are related to pressure gradient based on the Bernoulli equation,we used this parameter to predict increased platelet count after TIPS placement.Methods.A total of 161 consecutive patients who underwent TIPS placement entered this retrospective study.The platelet count was measured before,one week after and one month after TIPS placement.Clinically significant thrombocytopenia was defined as platelet count≤100000.Pre-and post-TIPS PPGs were measured.The velocity of blood flow in the proximal,mid and distal TIPS stent was measured using Doppler ultrasound,and the difference in the highest and lowest measured velocity was entitled flow velocity gradient(FVG),which was considered normal when≤100 cm/s.Results.In 121 patients with pre-TIPS thrombocytopenia,the mean platelet count one week and one month after TIPS placement increased 25.7×10^(3) and 35.0 × 10^(3) in 90 patients with PPG≤12mmHg(P=0.028 and P=0.015),while there was no significant change in platelet count in patients with a PPG>12mmHg(P=0.098 and P=0.075).Platelets increased significantly when FVG≤100 cm/s(n=95)vs FVG>100 cm/s(n=26)one week(37.0×10^(3) vs 11.0×10^(3);P=0.005 vs 0.07)and one month after TIPS placement(17.0×10^(3) vs 5.2×10^(3);P=0.01 vs 0.21).Conclusion.FVG>100 cm/s is not associated with increase in post-TIPS platelet count.On the other hand,findings suggestive of proper TIPS function(FVG≤100 cm/s and PPG≤12mmHg)predict a significant increase in post-TIPS platelet count.
