经皮穿刺直接性门腔分流术的应用解剖及临床应用

发布时间：2018-06-22 09:11

本文选题：经颈静脉门腔分流术 + 直接性门腔静脉分流术　；参考：《第二军医大学》2007年硕士论文

【摘要】： [背景]自1969年Rosch等首先进行经颈内静脉途径建立肝内门腔静脉分流(TIPS)的实验性研究以来,经过近40年的发展,TIPS术已成为介入性微创治疗门静脉高压及其并发症的主要手段之一。但TIPS术的主要缺陷在于难以持久地维持分流道的通畅性。有研究表明:TIPS术后6个月、12个月内分流道发生严重狭窄或闭塞的情况分别为17%～50%及23%～87%,约75%的狭窄或闭塞发生在TIPS术的引流静脉——肝静脉。由于TIPS术后有较高的分流道狭窄和闭塞,严重影响其远期疗效,也限制了该技术的进一步发展和应用,故TIPS术常被认为是一种暂时性门静脉减压术,这是TIPS术的最大不足之处。下腔静脉为人体内最大的静脉,其直径远宽于肝静脉,因而有学者提出了直接性门腔静脉分流(DIPS)的设想,将部分门脉血流直接分流入下腔静脉,希望获得通畅性更为稳定的分流道。DIPS术是在肝内门静脉与肝后段下腔静脉(RHSIVC)之间建立肝内分流,将部分门静脉血液直接分流入粗大的下腔静脉,它扩大了介入性门腔分流的适应症,可使部分难以实施TIPS术的患者也能做介入性门腔分流,成为介入性门腔分流的新热点。 2001年Petersen等首次报告了40例在血管内超声引导下行DIPS术的患者,经8～38个月随访,近中期疗效均较满意,门脉压由术前的16mmHg～38mmHg降至术后的9mmHg～24mmHg(平均降低10mmHg以上),出血控制率可达80%,腹水消失率达74%。DIPS术的近期疗效与TIPS术相当,无显著差异;而就远期疗效而言,DIPS术后引流静脉的狭窄、闭塞发生率远较TIPS术为低。据Quinn等报道,引流静脉1年的通畅率达60%;Petersen等报道更高,DIPS术后6个月引流静脉的通畅率为100%,12个月为75%。然而,Petersen等报道的是经RHSIVC直接穿刺肝内门静脉行DIPS术,常在血管内超声(IVUS)导引下进行。而我国肝硬化患者主要是肝炎后肝硬化,其肝脏质地较酒精性肝硬化患者的坚硬,穿刺困难;经RHSIVC从肝静脉汇入下腔静脉处穿刺门脉,穿刺点过高,支架易进入右心房,影响以后肝移植术的实施;此外,费用昂贵。为此,本研究拟探讨在彩超导引下经皮穿刺肝门静脉再至RHSIVC行DIPS术的可行性及安全性。彩超导引简单准确,费用低廉。 [目的]本研究旨在通过成人尸体肝脏标本的应用解剖学研究及肝硬化患者的影像学研究,进一步探讨DIPS术的可行性、安全性,以及在彩超导引下经皮直接穿刺肝门静脉再至RHSIVC行DIPS术的可行性及安全性,并初步评价DIPS术的临床疗效。 [方法] 1.采用经甲醛固定的成人离体肝脏标本30例,分别从脏面和膈面钝性剥离,充分显露门静脉左、右支和RHSIVC,分别测量门静脉左、右支的直径、走行及与RHSIVC的最近距离(其间距离最近两点可拟为穿刺点),以及RHSIVC的直径、长度和肝实质的包绕范围。2.随机选择慢性肝硬化患者30例,用彩超、CT、MRI进行肝脏二维或三维多切面扫描,测量肝脏大小、形态、回声,肝内门静脉左右支的内径、走行、流速,RHSIVC的直径、长度及肝实质的包绕范围,并分别测量门静脉左、右支及与RHSIVC的最近距离。3.选择肝硬化伴腹水或上消化道大出血的患者2例,在彩超引导下行DIPS术,分别对术前、术后患者的红细胞计数、血红蛋白量、肝功能、血氨水平及门脉主干压力的改变、腹水消退的情况进行比较,并采用彩色多普勒对分流道的通畅情况进行随访,评价DIPS术的近期和远期临床疗效。 [结果] 1.肝尾状叶包绕下腔静脉肝后段的形态,“C”形占56%(17例)、“U”形37%(11例)、“O”形6.6%(2例)。下腔静脉肝后段的长度及外径,分别为39.79±6.71 mm、26.63±4.51 mm。门静脉左支的主干长度、中点外径、中点与下腔静脉肝后段前壁距离,分别为33.97±5.88 mm、10.40±1.8 mm、24.80±7.79 mm。门静脉右支主干长度、中点外径、中点与下腔静脉肝后段前壁距离,分别为23.58±6.10 mm、9.77±2.01 mm、18.49±5.57 mm。下腔静脉前壁与门静脉右支间肝尾状叶的厚度12.0±4.68 mm。下腔静脉中点纵轴与门静脉左支角度30～45°,下腔静脉中点纵轴与门静脉右支角度15～25°。 2.彩超、CT、MRI测量的肝后段下腔静脉长度,分别为66.88±13.55mm、65.31±12.61 mm、68.11±14.80 mm,三者无统计学差异(p0.05);肝实质包绕的RHSIVC长度分别为14.71±7.55mm、14.31±6.61 mm、14.98±7.90 mm,三者无统计学差异(p0.05);肝内门脉左支距门脉分叉部1cm处与同层面RHSIVC之间的距离,分别为29.88±7.56mm、30.98±8.96 mm、31.58±7.95 mm,三者无统计学差异(p0.05);肝内门脉右支距门脉分叉部1cm处与同层面RHSIVC之间的距离,分别为24.58±6.66 mm、25.45±8.16 mm、27.10±8.66 mm,三者无统计学差异(p0.05)。 3. DIPS术的近期结果:2例DIPS术中肝内穿刺均获得成功,未出现术中与操作技术相关并发症。操作时间平均1.5h。造影分流道通畅,肝内门静脉分支充盈满意。食管胃底静脉曲张出血得到有效控制,难治性腹水迅速减少或消失。脾肿大及脾功能亢进症状得到明显缓解,相关实验室检查包括:血小板、血清总胆红素、血清蛋白、PT、SGPT等均有明显恢复。术后7d彩色多普勒对肝内血液动力学检查示:分流道内无湍流血流信号,血流速度比经肝静脉TIPS术分流更快;上消化道钡餐检查示:食管胃底静脉曲张基本消失,黏膜皱襞已基本连续,部分局部食管壁尚松弛。DIPS术后随访结果:2例患者术后均得到严格随访,每月行彩色多普勒超声、上消化道钡餐及相关实验室例行检查。随访至今,DIPS术后分流道内及支架两端均未出现因假性内膜过度增生所致的狭窄;Child-Pugh分级改善,平均术后3个月内,均改善至B级。DIPS术后各阶段随访,患者实验室检查结果稳定,术前门静脉高压并发症的临床症状未再出现。 [结论] 1.离体肝脏标本的应用解剖显示,肝后段下腔静脉及肝实质包绕的RHSIVC相对较长,实施DIPS是安全可行的;2.彩超、CT、MRI均能准确显示肝后段下腔静脉及门静脉,RHSIVC的平均长度为60.56±4.23mm, RHSIVC起、止层面的横断面平均有56.7%及93.1%的管腔被周围肝实质完全包绕;实施DIPS是安全可行的;3.在彩超导引下经皮穿刺肝门静脉再至RHSIVC行DIPS术简单、安全、可行,初步临床疗效满意。
[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.
【学位授予单位】：第二军医大学
【学位级别】：硕士
【学位授予年份】：2007
【分类号】：R322;R657.3

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