| Background:Liver cirrhosis is the terminal stage of chronic diffuse liver damage,which can be caused by one or more pathogenic factors.Common serious complications include esophagus and/or gastric varices,splenomegaly with or without hypersplenism,ascites,hepatic encephalopathy,hepatorenal syndrome,etc.Hemorrhage,anemia,and infection are the main symptoms of liver cirrhosis with hypersplenism.Laboratory examinations show that one or more lines of peripheral blood cell decrease,and bone marrow cytology indicates active bone marrow hyperplasia.Imaging examination can show enlargement of the spleen.After splenectomy,the peripheral blood cell can be close to or completely reach the normal range,and the symptoms can be significantly improved.Anemia caused by cirrhosis with hypersplenism will increase the incidence of spontaneous bleeding,thrombocytopenia will increase the risk of gastrointestinal bleeding,and limit the application of multiple drugs or the implementation of surgery and interventional therapy,leukopenia will increase the risk of systemic infection in patients and aggravates the degree of infection.Patients with liver cirrhosis and hypersplenism often have a variety of other serious complications,such as esophageal and/or gastric varices,large amounts of ascites,which significantly reduce the quality of life.Drug treatment for the cause and clinical symptoms is the first choice of treatment.For example,after standard medical treatment,surgery or interventional treatment may be considered when the symptoms are not relieved or the effect is poor.Traditional surgical treatment includes transjugular intrahepatic portosystemic intravenous stent shunt and laparoscopic splenectomy with pericardial vascular dissection.However,in addition to the high incidence of serious postoperative complications,traditional surgical treatment cannot be widely used in clinical practice.The development of minimally invasive vascular interventional technology has promoted the generation of minimally invasive interventional surgery for hypersplenism,PSE,which has the advantages of minimally invasive,mild postoperative complications and low morbidity.As an alternative "medical splenectomy",it is widely promoted in clinical practice and gradually improved and optimized in clinical application,and then has become the first choice for the treatment of hypersplenism.However,serious postoperative complications may occur,such as acute respiratory distress syndrome,infectious peritonitis,even if the incidence is low.Increasing the rate of splenic embolism can significantly improve the efficacy,but on the other hand,it will also increase the incidence of postoperative complications.Considering the balance of curative effect and surgical risk,how to make PSE safer and more effective is still controversial.Therefore,we designed the study to establish a predictive model for the efficacy of PSE in patients with liver cirrhosis and hypersplenism,and try to explore an individualized and appropriate splenic embolization treatment plan to fully improve the effect of thrombocytopenia and avoid serious complications.Objective:To screen the predictors of the postoperative efficacy of PSE in patients with liver cirrhosis and hypersplenism,and to determine the optimal treatment plan for individualized splenic embolism through the establishment of a predictive model for the efficacy of PSE.Methods:1.A total of 46 patients were enrolled from July 2018 to February 2020,all of whom underwent PSE surgery.Routine enhanced abdominal CT and portal vein CTA were performed before surgery and 1 month after surgery.The blood routine,liver function,coagulation function were performed before PSE,and 1 week,1 month,3 months,6 months,12 months after PSE.2.The inclusion criteria were as follows:①those diagnosed with liver cirrhosis and hypersplenism meeting the diagnostic criteria;②those successful underwent partial splenic artery embolization;③those have complete preoperative and postoperative examination data.The exclusion criteria were as follows:①Combined with other blood diseases that may cause thrombocytopenia;②Combined with other malignant diseases;③Combined with other infectious diseases;④Combined with ischemic heart disease;⑤Combined with heart or renal failure;⑥Combined with hepatic encephalopathy,prothrombin activity≤40%,total bilirubin level≥81.4 umol/L,moderate/large ascites.3.Record the gender,age,spleen volume before PSE,splenic infarction volume,and splenic embolism ratio of the enrolled patients,and compare the white blood cells,hemoglobin,platelets,serum albumin,and serum albumin,total bilirubin,blood creatinine,prothrombin time,Child-Pugh score before PSE and 1 week,1 month,3 months,6 months,12 months after PSE.A single factor linear regression model was used to screen the independent predicting factors for the efficacy of 1 year after PSE,a multiple linear regression model was used to further screen independent influencing factors and establish predictive regression model.single factor linear regression model was used to screen the effect of 1 year after PSE Independent predictive factors and establish a predictive regression model.Results:1.The postoperative non-infarcted spleen volume(461.5±222.5 mL)was significantly smaller than the preoperative spleen volume(1133.96±377.39 mL),and the difference is significant and statistically different(P<0.001).The infarcted spleen volume was 672.5±199.9 mL,the embolization rate was 60.68±8.74%.2.Of the 46 patients included in the study,35(76.09%)patients had one or more mild postoperative adverse reactions of varying degrees,and 6(13.04%)patients had severe complications,none of which had acute respiratory distress syndrome,splenic abscess,ruptured spleen,acute liver failure,hepatic encephalopathy and other serious complications.3.Peripheral blood white blood cell count of patients treated with PSE rose to the highest value at 1 week after surgery,and then gradually decreased over time.The overall trend was to increase first and then decrease;the hemoglobin level gradually increased after surgery,and the average value reached 12 months after surgery.Normal range;the platelet count gradually increased after the operation,rose to the highest value in 1 month after the operation,and then gradually decreased with time.The overall trend was to increase first and then decrease;the differences were statistically significant(P<0.05).4.Total bilirubin,albumin,spleen embolism rate,platelet count/spleen volume ratio(PSVR)are independent predictors of the growth rate of peripheral blood platelet count 1 year after PSE(P<0.05).Peripheral blood platelet count growth rate at 1 year after surgery=0.023 Xalbumin+1.576Xspleen embolization rate+0.008×total bilirubin-2.421×platelet count/spleen volume ratio 0.731,F=35.347,P<0.001,adjusted R2=0.753.5.Platelets,total bilirubin,albumin,non-infarct spleen volume,splenic embolism rate,platelet count/spleen volume ratio(PSVR)are independent predictors of the increase in peripheral blood platelet count at 1 year after PSE(P<0.05).Peripheral blood platelet count increase value at 1 year after operation=0.842×platelet count+1.516×albumin+58.882×spleen embolization rate 一0.022×non-infarct spleen volume-258.281 ×platelet count/spleen volume ratio-0.394×total bilirubin-62.344,F=42.591,P<0.001,adjust R2=0.847.6.In order to make the patient’s platelet count more than 75×109/L at 1 year after operation,the minimum embolized volume of the spleen=[(258.281 ×platelet count/spleen volume ratio+0.394×total bilirubin+137.344-1.842×platelet count 1.516×albumin)/(0.022×preoperative spleen volume+58.88)]×preoperative spleen volume.Conclusions:PSE can significantly improve the peripheral blood white blood cell,hemoglobin,and platelet count levels in patients with liver cirrhosis and hypersplenism,and is safe and effective for relieving hypersplenism.Preoperative albumin,total bilirubin,splenic embolism rate,non-infarct spleen volume and PSVR are important factors influencing the efficacy of PSE.In order to make the patient’s platelet count more than 75×109/L one year after operation and avoid serious complications,the prediction formula of the minimum embolism volume of the spleen with the patient’s one year platelet count>75×109/L before the operation can be used.Enter the patient’s albumin,total bilirubin,spleen volume,and platelet count to obtain the planned splenic embolization volume,and perform sequential PSE to avoid a single splenic embolism rate bigger than 50%,and a small amount of multiple embolization to avoid postoperative Complications and achieve the final embolization target value. |
PDF Full Text Request