内科治疗应该是腹水的标准治疗方法


  March 13, 2003 -一项刊载于三月份的Gastroenterology的研究结果显示,经颈静脉肝内门脉系统分流术(transjugular intrahepatic portosystemic shunts, TIPS) 加上内科治疗来控制腹水病情,比单独使用内科治疗来的更好,但是在改善生存率、住院率或生活质量等层面并没有较明显的优势。
  
  研究人员建议,内科治疗应该是主要的治疗方法,另外选择性的配合TIPS用于治疗移植或出血性静脉曲张病人。
  
  维吉尼亚医学院的Arun J. Sanyal, MD博士表示,最近普遍使用以TIPS治疗重症腹水,此TIPS治疗法可以降低门静脉的压力,不需要麻醉或手术就可纾解门静脉高压,但是TIPS治疗重症腹水的临床功效还不是十分清楚。
  
  研究中共有109例重症腹水的病换,其中57例为单独内科治疗组,包含限制钠的摄入、利尿剂治疗和放液穿刺术。另外52例为内科治疗加上TIPS组,分配方式采随随机分配。
  
  虽然在预防腹水复发方面,TIPS加上内科治疗优于单独内科治疗 (P < .001),其中两组的总体生存率相似,每组各有21例病人死亡,但TIPS组出现中等至严重程度脑病的趋势更明显 。
  
  比较两组肝衰竭、静脉曲张性出血以及急性肾衰竭的发生率皆相似,另外,急诊次数、住院次数以及生活质量在两组之间更没有明显的差别。
  
  并没有基线参数可以证实TIPS的效果是比较好或较差,作者推荐使用TIPS治疗的病患,以10-mm直径的膺管,与声纳描纪法或血管造影进行监控。
  
  作者表示,将TIPS用在静脉曲张性出血和相对保留肝脏功能的病人身上可能更为合理,但是对那些严重肝衰竭的病人而言,内科治疗将是更好的选择,且必须强调严重腹水的肝硬化病人肝脏移植是唯一的治疗方法,基于这些考量,我们相信对大多数病人而言,TIPS的使用应该为第二线的治疗或者作为肝移植的桥梁,特别是那些相对保留肝脏功能的病人。

Medical Therapy, Not TIPS, Sho

By Laurie Barclay, MD
Medscape Medical News

March 13, 2003 — Transjugular intrahepatic portosystemic shunts (TIPS) plus medical therapy is better than medical therapy alone in controlling ascites, but not in improving survival, hospitalization rates, or quality of life, according to the results of a multicenter, prospective trial reported in the March issue of Gastroenterology. The investigators suggest that medical therapy should be the principal therapy, with TIPS being offered selectively as a bridge to transplant or for patients with bleeding varices.

"TIPS have recently been used for the treatment of patients with refractory ascites. TIPS decompress the portal vein and correct portal hypertension without the need for general anesthesia or major surgery," write Arun J. Sanyal, MD, from the Medical College of Virginia in Richmond, and colleagues from the North American Study for the Treatment of Refractory Ascites Group. "The clinical utility of TIPS vis-a-vis total paracentesis in the management of refractory ascites is unclear."

Of 109 subjects with refractory ascites, 57 were randomized to medical therapy alone, consisting of sodium restriction, diuretics, and total paracentesis, and 52 were randomized to medical therapy plus TIPS. Shunting was technically adequate in 49 of 52 subjects.

Although TIPS plus medical therapy was superior to medical therapy alone in preventing recurrence of ascites (P < .001), overall and transplant-free survival were similar in both groups, with 21 deaths in each group. Moderate to severe encephalopathy showed a trend toward being more common in the TIPS group (20 of 52 vs. 12 of 57; P = .058).

The two groups were similar in rates of liver failure (7 vs. 3), variceal hemorrhage (5 vs. 8), and acute renal failure (3 vs. 2). The frequency of emergency department visits, medically indicated hospitalizations, and quality of life also did not differ significantly between groups, nor did TIPS obviate the need for sodium restriction.

No baseline parameters identified a subset of patients who did better or worse after TIPS placement. In those patients treated with TIPS, the authors recommend initial placement of a 10-mm diameter TIPS, not pursuing a hepatic venous pressure gradient target of 8 mm Hg or less, and follow-up sonography or angiography to monitor for stent stenosis.

"TIPS may be more reasonable in an individual with variceal hemorrhage and relatively preserved liver function, whereas medical therapy may be a better option for those with advanced liver failure. It is also important to note that liver transplantation is the only definitive treatment of cirrhosis with refractory ascites," the authors write. "Based on these considerations, we believe the use of TIPS should be reserved in most instances as second-line therapy or a bridge to liver transplantation, particularly for those with relatively preserved liver function."

Gastroenterology. 2003; 124:634-641

Reviewed by Gary D. Vogin, MD

    
相关报导
自动细胞计数有助于原发性细菌性腹膜炎的诊断
2003/9/5 上午 11:14:00

上一页
   1  
下一页




回上一页