本文選題：經(jīng)頸靜脈門腔分流術(shù) + 直接性門腔靜脈分流術(shù)�。� 參考：《第二軍醫(yī)大學(xué)》2007年碩士論文

【摘要】： [背景]自1969年Rosch等首先進(jìn)行經(jīng)頸內(nèi)靜脈途徑建立肝內(nèi)門腔靜脈分流(TIPS)的實(shí)驗(yàn)性研究以來,經(jīng)過近40年的發(fā)展,TIPS術(shù)已成為介入性微創(chuàng)治療門靜脈高壓及其并發(fā)癥的主要手段之一。但TIPS術(shù)的主要缺陷在于難以持久地維持分流道的通暢性。有研究表明:TIPS術(shù)后6個(gè)月、12個(gè)月內(nèi)分流道發(fā)生嚴(yán)重狹窄或閉塞的情況分別為17%～50%及23%～87%,約75%的狹窄或閉塞發(fā)生在TIPS術(shù)的引流靜脈——肝靜脈。由于TIPS術(shù)后有較高的分流道狹窄和閉塞,嚴(yán)重影響其遠(yuǎn)期療效,也限制了該技術(shù)的進(jìn)一步發(fā)展和應(yīng)用,故TIPS術(shù)常被認(rèn)為是一種暫時(shí)性門靜脈減壓術(shù),這是TIPS術(shù)的最大不足之處。 下腔靜脈為人體內(nèi)最大的靜脈,其直徑遠(yuǎn)寬于肝靜脈,因而有學(xué)者提出了直接性門腔靜脈分流(DIPS)的設(shè)想,將部分門脈血流直接分流入下腔靜脈,希望獲得通暢性更為穩(wěn)定的分流道。DIPS術(shù)是在肝內(nèi)門靜脈與肝后段下腔靜脈(RHSIVC)之間建立肝內(nèi)分流,將部分門靜脈血液直接分流入粗大的下腔靜脈,它擴(kuò)大了介入性門腔分流的適應(yīng)癥,可使部分難以實(shí)施TIPS術(shù)的患者也能做介入性門腔分流,成為介入性門腔分流的新熱點(diǎn)。 2001年P(guān)etersen等首次報(bào)告了40例在血管內(nèi)超聲引導(dǎo)下行DIPS術(shù)的患者,經(jīng)8～38個(gè)月隨訪,近中期療效均較滿意,門脈壓由術(shù)前的16mmHg～38mmHg降至術(shù)后的9mmHg～24mmHg(平均降低10mmHg以上),出血控制率可達(dá)80%,腹水消失率達(dá)74%。DIPS術(shù)的近期療效與TIPS術(shù)相當(dāng),無顯著差異;而就遠(yuǎn)期療效而言,DIPS術(shù)后引流靜脈的狹窄、閉塞發(fā)生率遠(yuǎn)較TIPS術(shù)為低。據(jù)Quinn等報(bào)道,引流靜脈1年的通暢率達(dá)60%;Petersen等報(bào)道更高,DIPS術(shù)后6個(gè)月引流靜脈的通暢率為100%,12個(gè)月為75%。 然而,Petersen等報(bào)道的是經(jīng)RHSIVC直接穿刺肝內(nèi)門靜脈行DIPS術(shù),常在血管內(nèi)超聲(IVUS)導(dǎo)引下進(jìn)行。而我國肝硬化患者主要是肝炎后肝硬化,其肝臟質(zhì)地較酒精性肝硬化患者的堅(jiān)硬,穿刺困難;經(jīng)RHSIVC從肝靜脈匯入下腔靜脈處穿刺門脈,穿刺點(diǎn)過高,支架易進(jìn)入右心房,影響以后肝移植術(shù)的實(shí)施;此外,費(fèi)用昂貴。為此,本研究擬探討在彩超導(dǎo)引下經(jīng)皮穿刺肝門靜脈再至RHSIVC行DIPS術(shù)的可行性及安全性。彩超導(dǎo)引簡單準(zhǔn)確,費(fèi)用低廉。 [目的]本研究旨在通過成人尸體肝臟標(biāo)本的應(yīng)用解剖學(xué)研究及肝硬化患者的影像學(xué)研究,進(jìn)一步探討DIPS術(shù)的可行性、安全性,以及在彩超導(dǎo)引下經(jīng)皮直接穿刺肝門靜脈再至RHSIVC行DIPS術(shù)的可行性及安全性,并初步評價(jià)DIPS術(shù)的臨床療效。 [方法] 1.采用經(jīng)甲醛固定的成人離體肝臟標(biāo)本30例,分別從臟面和膈面鈍性剝離,充分顯露門靜脈左、右支和RHSIVC,分別測量門靜脈左、右支的直徑、走行及與RHSIVC的最近距離(其間距離最近兩點(diǎn)可擬為穿刺點(diǎn)),以及RHSIVC的直徑、長度和肝實(shí)質(zhì)的包繞范圍。2.隨機(jī)選擇慢性肝硬化患者30例,用彩超、CT、MRI進(jìn)行肝臟二維或三維多切面掃描,測量肝臟大小、形態(tài)、回聲,肝內(nèi)門靜脈左右支的內(nèi)徑、走行、流速,RHSIVC的直徑、長度及肝實(shí)質(zhì)的包繞范圍,并分別測量門靜脈左、右支及與RHSIVC的最近距離。3.選擇肝硬化伴腹水或上消化道大出血的患者2例,在彩超引導(dǎo)下行DIPS術(shù),分別對術(shù)前、術(shù)后患者的紅細(xì)胞計(jì)數(shù)、血紅蛋白量、肝功能、血氨水平及門脈主干壓力的改變、腹水消退的情況進(jìn)行比較,并采用彩色多普勒對分流道的通暢情況進(jìn)行隨訪,評價(jià)DIPS術(shù)的近期和遠(yuǎn)期臨床療效。 [結(jié)果] 1.肝尾狀葉包繞下腔靜脈肝后段的形態(tài),“C”形占56%(17例)、“U”形37%(11例)、“O”形6.6%(2例)。下腔靜脈肝后段的長度及外徑,分別為39.79±6.71 mm、26.63±4.51 mm。門靜脈左支的主干長度、中點(diǎn)外徑、中點(diǎn)與下腔靜脈肝后段前壁距離,分別為33.97±5.88 mm、10.40±1.8 mm、24.80±7.79 mm。門靜脈右支主干長度、中點(diǎn)外徑、中點(diǎn)與下腔靜脈肝后段前壁距離,分別為23.58±6.10 mm、9.77±2.01 mm、18.49±5.57 mm。下腔靜脈前壁與門靜脈右支間肝尾狀葉的厚度12.0±4.68 mm。下腔靜脈中點(diǎn)縱軸與門靜脈左支角度30～45°,下腔靜脈中點(diǎn)縱軸與門靜脈右支角度15～25°。 2.彩超、CT、MRI測量的肝后段下腔靜脈長度,分別為66.88±13.55mm、65.31±12.61 mm、68.11±14.80 mm,三者無統(tǒng)計(jì)學(xué)差異(p0.05);肝實(shí)質(zhì)包繞的RHSIVC長度分別為14.71±7.55mm、14.31±6.61 mm、14.98±7.90 mm,三者無統(tǒng)計(jì)學(xué)差異(p0.05);肝內(nèi)門脈左支距門脈分叉部1cm處與同層面RHSIVC之間的距離,分別為29.88±7.56mm、30.98±8.96 mm、31.58±7.95 mm,三者無統(tǒng)計(jì)學(xué)差異(p0.05);肝內(nèi)門脈右支距門脈分叉部1cm處與同層面RHSIVC之間的距離,分別為24.58±6.66 mm、25.45±8.16 mm、27.10±8.66 mm,三者無統(tǒng)計(jì)學(xué)差異(p0.05)。 3. DIPS術(shù)的近期結(jié)果:2例DIPS術(shù)中肝內(nèi)穿刺均獲得成功,未出現(xiàn)術(shù)中與操作技術(shù)相關(guān)并發(fā)癥。操作時(shí)間平均1.5h。造影分流道通暢,肝內(nèi)門靜脈分支充盈滿意。食管胃底靜脈曲張出血得到有效控制,難治性腹水迅速減少或消失。脾腫大及脾功能亢進(jìn)癥狀得到明顯緩解,相關(guān)實(shí)驗(yàn)室檢查包括:血小板、血清總膽紅素、血清蛋白、PT、SGPT等均有明顯恢復(fù)。術(shù)后7d彩色多普勒對肝內(nèi)血液動力學(xué)檢查示:分流道內(nèi)無湍流血流信號,血流速度比經(jīng)肝靜脈TIPS術(shù)分流更快;上消化道鋇餐檢查示:食管胃底靜脈曲張基本消失,黏膜皺襞已基本連續(xù),部分局部食管壁尚松弛。DIPS術(shù)后隨訪結(jié)果:2例患者術(shù)后均得到嚴(yán)格隨訪,每月行彩色多普勒超聲、上消化道鋇餐及相關(guān)實(shí)驗(yàn)室例行檢查。隨訪至今,DIPS術(shù)后分流道內(nèi)及支架兩端均未出現(xiàn)因假性內(nèi)膜過度增生所致的狹窄;Child-Pugh分級改善,平均術(shù)后3個(gè)月內(nèi),均改善至B級。DIPS術(shù)后各階段隨訪,患者實(shí)驗(yàn)室檢查結(jié)果穩(wěn)定,術(shù)前門靜脈高壓并發(fā)癥的臨床癥狀未再出現(xiàn)。 [結(jié)論] 1.離體肝臟標(biāo)本的應(yīng)用解剖顯示,肝后段下腔靜脈及肝實(shí)質(zhì)包繞的RHSIVC相對較長,實(shí)施DIPS是安全可行的;2.彩超、CT、MRI均能準(zhǔn)確顯示肝后段下腔靜脈及門靜脈,RHSIVC的平均長度為60.56±4.23mm, RHSIVC起、止層面的橫斷面平均有56.7%及93.1%的管腔被周圍肝實(shí)質(zhì)完全包繞;實(shí)施DIPS是安全可行的;3.在彩超導(dǎo)引下經(jīng)皮穿刺肝門靜脈再至RHSIVC行DIPS術(shù)簡單、安全、可行,初步臨床療效滿意。
[Abstract]:[background] since Rosch and other experimental studies on the establishment of intrahepatic portal vena cava shunt (TIPS) by the internal jugular vein in 1969, after nearly 40 years of development, TIPS has become one of the main means of interventional minimally invasive treatment of portal hypertension and its complications. However, the main defect of TIPS is that it is difficult to maintain the distributary canal for a long time. A study showed that 6 months after TIPS, severe stenosis or occlusion occurred within 12 months of 17% to 50% and 23% to 87%, and about 75% of the stenosis or occlusion occurred in the drainage vein of TIPS, the hepatic vein. Due to the higher shunt stenosis and occlusion after TIPS, the long term effect was seriously affected and it was limited. With the further development and application of technology, TIPS is often regarded as a temporary decompression of portal vein, which is the biggest deficiency of TIPS.
The inferior vena cava is the largest vein in the human body, and its diameter is far wider than the hepatic vein. Therefore, some scholars have proposed direct portal vena cava shunt (DIPS), which distributary partial portal blood flow directly into the inferior vena cava, hoping to obtain smooth and more stable shunt.DIPS which is built between the intrahepatic portal vein and the posterior inferior vena cava (RHSIVC). Intrahepatic shunt, which distributary part of the portal vein blood directly into the large inferior vena cava, expands the indication of the interventional portal shunt, and can make the patients who are difficult to implement TIPS can also do interventional portal shunt and become a new hot spot of interventional portal shunt.
In 2001, 40 cases of Petersen were reported for the first time with intravascular ultrasound guided DIPS. After 8~38 months of follow-up, the curative effect was satisfactory. The portal pulse pressure was reduced from 16mmHg to 38mmHg before operation to 9mmHg to 24mmHg (the average decrease of 10mmHg above). The control rate of bleeding could reach 80%. The disappearance rate of ascites reached the short-term curative effect of 74%.DIPS operation. There was no significant difference in TIPS, but for the long term effect, the stenosis and occlusion rate of drainage veins after DIPS was much lower than that of TIPS. According to Quinn and other reports, the patency rate of 1 years was 60%, Petersen and other reports were higher. The patency rate of drainage veins was 100% and 12 months was 75%. after 6 months of DIPS.
However, Petersen and others reported that DIPS was performed by direct RHSIVC puncture in the intravascular portal vein, often under the guidance of intravascular ultrasound (IVUS). In China, patients with liver cirrhosis were mainly cirrhosis of the liver, and their liver texture was hard and difficult to puncture; puncture the portal vein from the hepatic vein to the inferior vena cava from the hepatic vein and puncturing by RHSIVC. It is easy to enter the right atrium and affect the implementation of the liver transplantation. In addition, the cost is expensive. For this reason, this study is to explore the feasibility and safety of the percutaneous puncture of the hepatic portal vein to RHSIVC under the guidance of color Doppler ultrasound. The color Doppler ultrasound guidance is simple and accurate and the cost is low.
[Objective] the purpose of this study was to explore the feasibility and safety of DIPS, as well as the feasibility and safety of DIPS by direct percutaneous puncture of the hepatic portal vein to RHSIVC under the guidance of color Doppler ultrasound, and to evaluate the clinical efficacy of DIPS.
[Methods] 1. (1.) 30 cases of adult isolated liver specimens were fixed by formaldehyde. The left, right branches and RHSIVC of the portal vein were fully exposed. The left and right branches of the portal vein were fully revealed. The diameter of the left and right branches of the portal vein, the shortest distance from the RHSIVC, and the diameter of the RHSIVC, the length and the liver of the liver were measured at the nearest distance of the nearest two points. .2. randomly selected 30 patients with chronic cirrhosis. The liver size, shape, echo, the internal diameter of the left and right branches of the hepatic portal, the diameter of the RHSIVC, the diameter of the RHSIVC, the length of the liver and the scope of the liver were measured, and the left and right branches of the portal vein and RHSIVC were measured respectively. 2 patients with severe hemorrhage from cirrhosis with ascites or upper gastrointestinal tract were selected by.3., and the red blood cell count, hemoglobin amount, liver function, blood ammonia level, portal vein pressure and ascites decline were compared before and after color Doppler guided DIPS. Color Doppler was used for the flow of shunt. Follow up was performed to evaluate the short-term and long-term clinical outcomes of DIPS.
[results] 1. "C" shape accounted for 56% (17 cases), "U" shape 37% (11 cases), and "O" 6.6% (2 cases). The length and outer diameter of the posterior segment of the inferior vena cava were 39.79 + 6.71 mm, 26.63 + 4.51 mm. of the left branch of the left branch of the portal vein, the distance between the middle point and the anterior wall of the inferior vena cava, respectively. The length of the main trunk of the right branch of the portal vein was 33.97 + 5.88 mm, 10.40 + 1.8 mm and 24.80 + 7.79 mm.. The distance between the middle point and the anterior wall of the posterior segment of the inferior vena cava was 23.58 + 6.10 mm, 9.77 + 2.01 mm respectively, and the thickness of the caudate lobe of the right branch of the portal vein in the anterior wall of the inferior vena cava and the inferior vena cava of the inferior vena cava and the middle point of the inferior vena cava in the inferior vena cava and the middle point of the inferior vena cava in the inferior vena cava The angle is 30~45 degrees, the longitudinal axis of the inferior vena cava is 15~25 degrees from the right branch of the portal vein.
2. the length of inferior vena cava of the posterior segment of the liver measured by color Doppler ultrasound, CT and MRI were 66.88 + 13.55mm, 65.31 + 12.61 mm, 68.11 + 14.80 mm, and three were not statistically different (P0.05). The length of the liver parenchyma wrapped around the liver was 14.71 + 7.55mm, 14.31 + 6.61 mm, 14.98 + 7.90 mm, and three were not statistically different (P0.05); the left branch of the intrahepatic portal vein was apart from the portal bifurcation of the portal vein. The distance between the RHSIVC and the same level was 29.88 + 7.56mm, 30.98 + 8.96 mm, 31.58 + 7.95 mm, and there was no statistical difference (P0.05). The distance between the right branch of the right branch of the portal vein of the portal vein and the same level RHSIVC was 24.58 + 6.66 mm, 25.45 + 8.16 mm, 27.10 + 8.66 mm, and there was no statistical difference (P0.05).
The recent results of 3. DIPS: 2 cases of intrahepatic puncture were successful in all DIPS cases, no complications were associated with operation techniques. The operation time was unobstructed by the operation time of 1.5h. contrast channel, the branch of the hepatic portal vein was satisfied. The bleeding of the esophageal varices was effectively controlled and the refractory ascites decreased rapidly or disappeared. Splenomegaly and splenic work The symptoms of hyperthyroidism were obviously relieved, and the related laboratory examination included: platelet, serum total bilirubin, serum protein, PT, SGPT, and so on. The postoperative hemodynamic examination of 7D color Doppler showed that there was no turbulent flow signal in the distributary channel, the velocity of blood flow was faster than that of TIPS by hepatic vein, and the barium meal examination of upper digestive tract showed: The gastric fundus varicosity of the esophagus basically disappeared, the mucosa folds were basically continuous, and some local esophageal walls were followed up after.DIPS operation. 2 patients were followed up strictly after operation. Color Doppler ultrasound, upper digestive tract barium meal and related laboratory routine examination were performed every month. Up to now, the two ends of the shunt and stent after DIPS have not appeared. Because of the stenosis caused by pseudointima hyperplasia, the Child-Pugh grade was improved, and the average after 3 months after the operation was improved to all stages after B.DIPS. The results of the patient's laboratory examination were stable and the clinical symptoms of the complications of the anterior portal hypertension were not reappeared.
[Conclusion] the applied anatomy of the 1. isolated liver specimens showed that the RHSIVC of the inferior vena cava and the hepatic parenchyma was relatively long in the posterior segment of the liver, and the implementation of DIPS was safe and feasible. 2. color Doppler ultrasound, CT and MRI could accurately show the inferior vena cava and the portal vein in the posterior segment of the liver, the average length of RHSIVC was 60.56 + 4.23mm, RHSIVC, and the average of 56.7% and 93.1 cross sections. % of the cavities are completely wrapped around the parenchyma of the surrounding liver; it is safe and feasible to implement DIPS; 3. the percutaneous puncture of the hepatic portal vein to RHSIVC under the guidance of color Doppler ultrasound is simple, safe and feasible, and the preliminary clinical effect is satisfactory.
【學(xué)位授予單位】：第二軍醫(yī)大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2007
【分類號】：R322;R657.3

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