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目的:分析诱发经颈静脉途径肝内门-腔静脉分流术(TIPSS)后肝性脑病(HE)的潜在因素,探讨预防措施。资料和方法:1993年3月～1997年3月间行TIPSS264例,分析与HE相关的因素有:患者性别、年龄,肝功能分级,肝硬化及肝萎缩程度,急诊或择期分流,所使用支架类型及直径,术中有否栓塞胃冠状静脉,术后门一腔静脉梯度压(PCG),血氨浓度,Doppler超声波显示的血流方向。结果:HE发生率为16.03％(33/212),其中术前存在HE症状、术后加重2例,术后无其它诱发因素、新出现HE症状31例。HE的发生率与肝功能分级之间呈高度相关(γ=0.86)。内支架直径与HE的关系:直径8mm组HE发生率为7.31％(3/41)。直径10mm组发发率为17.54％(31/171),两组之间差别有显著性(P<0.01)。Doppler超声显示门静脉属完全离肝型、部分离肝性及向肝血流型HE发生率分别为60.0％(21/35)、13.56％(8/59)、3.38％(4/118),三组之间差别有显著性(P<0.01)。统计结果还表明,术后HE的其它高危因素有明显肝萎缩、分流道较直、术后PCG明显降低(≤10mmHg)、急诊病例、术后血氨持续增高及术中未栓塞曲张的胃冠状静脉。多元回归分析结果提示,在与HE相关的诸多因素中,作用最大者为肝功能分级,其次为所用内支架直径、术后门静脉的血流方向。患者的年龄、性别、所使用支架的类型与术后HE的发发率无相关性。结论:TIPSS后HE的高危因素主要有肝硬化肝功能失代偿、所用内支架的直径较大及术后门静脉呈离肝血流。从严掌握适应证、用直径≤8mm支架及术中栓塞胃冠状静脉可减少HE的发生率。
Objective: To analyze the underlying factors of hepatic encephalopathy (HE) after transjugular intra-hepatic portal-venovenous shunt (TIPSS) and to investigate the preventive measures. Materials and Methods: TIPSS was performed in 264 patients from March 1993 to March 1997. The factors related to HE were analyzed: gender, age, grade of liver function, degree of liver cirrhosis and liver atrophy, emergency or elective shunt, Type and diameter, whether coronary artery embolization surgery, postoperative vena cava gradient pressure (PCG), blood ammonia concentration, Doppler ultrasound shows the direction of blood flow. Results: The incidence of HE was 16.03% (33/212). There were HE symptoms preoperatively and 2 cases postoperatively. There were no other inducing factors after operation. There were 31 new cases of HE symptoms. The incidence of HE was highly correlated with the grade of liver function (γ = 0.86). The relationship between the diameter of stent and HE: The incidence of HE in diameter 8mm group was 7.31% (3/41). The incidence rate of 10mm diameter group was 17.54% (31/171), the difference between the two groups was significant (P <0.01). Doppler ultrasound showed that the portal vein was completely separated from the liver and the incidence of partial hepatic hemorrhage and hepatic hemorrhage were 60.0% (21/35), 13.56% (8/59), 3.38% (4/118) respectively, The difference between the groups was significant (P <0.01). Statistical results also showed that other high risk factors for postoperative HE were significant liver atrophy, shunt straight, postoperative PCG was significantly lower (≤ 10mmHg), emergency cases, postoperative blood ammonia continued to increase and intraoperative non-embolized varices gastric vein. Multivariate regression analysis showed that among the many factors associated with HE, the greatest effect was grading of liver function, followed by the diameter of the stent used and the direction of the portal vein after the operation. The patient’s age, gender, type of stent used had no correlation with postoperative HE incidence. Conclusion: The high risk factors of HE after TIPSS mainly include liver cirrhosis decompensation, large diameter of stent used and postoperative portal vein blood flow from the liver. Strict control of indications, with diameter ≤ 8mm stent and intraoperative embolization of gastric coronary vein can reduce the incidence of HE.