| Objectives To study the postoperative survival of patients undergoing transjugular intrahepatic portalsystemic shunt(TIPS),and to investigate the risk factors and preventive measures for Hepatic encephalopathy(HE)after TIPS.Methods 32 patients undergoing TIPS from January 1,2015 to December 31,2018 were divided into HE group(n=9)and non-HE group(n=23),according to the occurrence of HE after operation.Age,sex and etiology of portal hypertension were recorded.Child-Pugh grading of liver function before operation,portal pressure gradient(PPG),location of portal puncture and stent diameter were calculated.The levels of total bilirubin,albumin,prothrombin time(prothrombin time,PT),glutamic-pyruvic transaminase(alanine aminotransferase,ALT)and blood ammonia were recorded before operation,1 week after operation,1 month after operation,3 months after operation and HE.1 d before and 1 week,1 month,3 month after operation and postoperative HE in effect at the time of albumin,prothrombin time(PT),alanine aminotransferase(ALT),blood ammonia and total bilirubin levels were compared in the two groups.The corresponding data were tested by ?2 test and t-test.Logistic regression analysis was used to analyze the risk factors of HE by univariate and multivariate analysis.The area under ROC curve,95%C.I.and P values were used to evaluate the effectiveness of each indicator.Results The median follow-up time of 32 patients was 12 months,and the longest follow-up time was 46 months(3.8 years).During the follow-up period,a total of 9 cases of HE occurred,with a total incidence of 28.13%.The peak of HE occurred in the early stage after TIPS(within 12 months),1 patient developed HE 3 months after TIPS and died of liver cancer 5 months after TIPS.1 patient developed HE,12 months after operation and died of liver failure.The other 7 cases were alleviated by medical treatment.Pre-TIPS levels of total bilirubin and blood ammonia in HE group and non-HE group were significantly different(P=0.024 and 0.004);at the time of HE occurrence,the level of blood ammonia[(106.8±51.15)?mol/L]in HE group was significantly higher than that before TIPS(P=0.013);incidence of HE in patients with Child-Pugh grade C was higher than that in patients with grade A(P=0.068,belonging to 0.05?0.1,consistent with the significant boundary);incidence of HE in Child-Pugh grade C patients was higher than that in grade B patients,and the incidence of grade B HE was also higher than that in grade A patients,but the difference was not statistically significant(P>0.05);the decrease of PPG in HE group was significantly higher than that in non-HE group(t=2.55,P=0.016);incidence of HE in the right branch of the portal vein was higher than that in the left branch of the portal vein(P=0.053,belonging to 0.05?0.1,consistent with the significant boundary);incidence of HE with an internal diameter of 10mm was higher than that with an internal diameter of 8mm(P=0.036).The results of ROC curve and AUC showed that the AUC of Child-Pugh classification,portal vein puncture location,PPQ preoperative total bilirubin and preoperative blood ammonia were 0.739,0.679,0.727,0.756,0.758 and 0.771 respectively(P<0.05).The predictive value of each index for HE after TIPS was:preoperative blood ammonia>preoperative total bilirubin>PPG>Child-Pugh classification>portal vein puncture location>stent diameter.Logistic multivariate regression analysis suggested that the internal diameter of stent and the decrease of PPG are independent risk factors for HE after TIPS.Conclusions Incidence of hepatic encephalopathy can be significantly reduced by actively improving nutritional status and liver function,reducing blood ammonia,selecting left portal vein branch as portacaval shunt,implanting 8 mm inner diameter stent and controlling the descent of portal vein pressure gradient at 8-12 cmH20. |
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