门静脉左支分流降低术后肝性脑病的临床研究

目的 检测和分析家兔门静脉及其分支的血氨浓度差异从而指导肝内门腔静脉分流术中对门静脉分支的选择,降低分流引起的肝性脑病的发病率。评价选择性门静脉左支作为经颈静脉肝内门腔静脉分流术分流道的临床意义,分析门静脉左、右支的血液动力学变化及重要液递物质浓度差异对术后预防肝性脑病及远期疗效的影响。方法 在家兔门静脉系统各分支分别取血测定血氨浓度并进行比较。341例有目的地选择肝内门静脉左支作为穿刺靶点,行经颈静脉肝内门静脉左支门腔分流术(transjugular intrahepatic leftbranch of portal vein portosystemicshunt,TILPS)建立门腔分流道,避开富含营养、毒素的门静脉右支血液。肝实质通道用8mm直径球囊扩张,限制分流口径。结果 所测得血氨浓度,肠系膜上静脉高于门静脉左、右主支,(19.3±19.3)μmol/L与(156.5±20.9)μmol/L、(176.3±22.5)μmol/L,t值为2.35、2.25,P<0.05;高于脾静脉与腔静脉;门静脉右支高于左支、所有患者术后3个月内无一例发生肝性脑病。随访期间(术后1年),TILPS术后341例患者仅5例 (1.47％)出现肝性脑病,19例(5.57％)出现支架内狭窄。结论 家兔门静脉系统各分支的血氨浓度存在差异,提示肝内门腔静脉分流术中门静脉左右支的选择可能会影响术后肝性脑病的发病率。选

Portosystemic shunt via the left branch of portal vein for the prevention of encephalopathy following transjugular intrahepatic portosystemic shunt

Objective To determine and analyze plasma ammonia concentration difference of the portal vein system and ramifications of rabbits and consequently guide selection of the portal vein in transjugular intrahepatic portosystemic shunt (TIPS) so that reduce shunt-induced hepatic encephalopathic incidence. To evaluate clinical significance of transjugular intrahepatic left branch of portal vein portosystemic shunt (TILPS) and to analyse hemodynamics of both branches of the portal vein and to observe long-term results in the prevention of encephalopathy. Methods Blood samples in different portal vein branches of rabbits were collected and the plasma ammonia concentration was assayed and compared. The left branch of portal vein was used as the puncture site to perform TILPS and to keep away from the right branch of portal vein blood that contains nutrition and toxin. Results Plasma ammonia content was superior in the mesenteric vein and higher than the portal vein branch, the splenic vein, and the vena cava. The right portal vein was above the left. Encephalopathy did not occur in all patients within 3 months. Of the 341 patients undergoing TILPS, encephalopathy occurred in only 5 patients (1.47%) and shunt abnormalities in 19 patients (5.57%) verified by venography during overall follow-up period. Conclusions Selective left branch of the portal vein portosystemic shunt can decrease encephalopathy obviously and protect liver function.