Efficacy And Safety Of Transjugular Intrahepatic Portosystemic Shunt In The Treatment Of Hepatocellular Carcinoma Complicated With Esophageal And Gastric Varices Bleeding

Background:Hepatocellular carcinoma（HCC）is one of the leading causes of cancer death worldwide,with high malignancy and mortality.Portal hypertension（PVH）is often accompanied by hepatocellular carcinoma（HCC）which are common late complications in patients with cirrhosis.Portal hypertension is often accompanied by hepatocellular carcinoma（HCC）at the same time.Esophageal and gastric varices bleeding is one of the main causes of death in HCC patients with PVH.Transjugular intrahepatic portosystemic shunt（TIPS）is an effective method for the treatment of portal hypertension and its complications.Whether TIPS is suitable for patients with hepatocellular carcinoma complicated with esophageal and gastric varices bleeding remains to be determined.Objective:To evaluate the efficacy,safety and application value of TIPS in the treatment of hepatocellular carcinoma with esophageal and gastric variceal bleeding by retrospective analysis of the curative effect,complications and overall survival rate of patients with hepatocellular carcinoma and cirrhosis combined with esophagogastric variceal hemorrhage.Methods:From May 2011 to December 2016,25 hepatocellular carcinoma patients with EGVB（experimental group）and 289 cirrhosis patients with EGVB（control group）were hospitalized in the Second Affiliated Hospital of Chongqing Medical University and treated with TIPS.Preoperative laboratory examinations were followed up.The results of examination and imaging were followed up by clinic and telephone post-operation.The patients were followed-up either until December 2018or until death.Follow-up items included hepatic encephalopathy,rebleeding,incidence of stent dysfunction,time of death and causes.The main analysis indicators included the success rate of operation,the decrease of portal vein pressure after operation,serious complications related to operation,perioperative mortality and cumulative survival rate.Results:25 cases in the experimental group were all male,with a median age of 52 years,289 cases in the control group,223 males and 66females,with a median age of 48 years.Postoperative mean portal vein pressure in the experimental group decreased by（10.24±6.20）cmH₂0（1 cmH₂0=0.098 kPa）with statistical significance（p<0.05）.The success rate of TIPS was 100%.There was no seriou complications and perioperative death.During the follow-up period,3 patients developed hepatic encephalopathy,all of which were at degree II.7 patients suffered from upper gastrointestinal re-bleeding,5 patients died of massive hemorrhage of upper gastrointestinal tract,and 4 patients suffered from stent dysfunction.（2）Postoperative portal pressure gradient decreased in the control group（11.03±5.53）cmH₂0 on average,with statistical significance（p<0.05）.The success rate of TIPS was 98.27%.There were 5 perioperative deaths due to abdominal hemorrhage,upper gastrointestinal re-bleeding or liver failure.During the follow-up period,67 cases had hepatic encephalopathy and 56 cases had upper gastrointestinal re-bleeding,47 died cases including24 cases of liver cancer or liver failure,17 cases of esophageal and gastric varices bleeding,2 cases of hepatic encephalopathy and 4 cases of other death reasons and 35 cases of stent dysfunction（3）Cox multivariate analysis showed that preoperative high alkaline phosphatase level[hazard ratio（HR）=1.027,95%confidence interval（95%CI）:1.008-1.046,P=0.0004]was an independent risk factor for long-term survival of patients with hepatocellular carcinoma complicated with esophageal and gastric varices bleeding after TIPS treatment;elder age[HR=1.042,95%CI:1.008-1.077,P=0.014],hepatic encephalopathy after operation[HR=2.0.28,95%CI:1.077-3.819,P=0.028],postoperative upper gastrointestinal bleeding[HR=2.104,95%CI:1.080-4.100,P=0.029],higherγ-GT[HR=1.006,95%CI:1.000-1.012,P=0.036],low cholinesterase level[HR=0.474,HR=0.474,95%CI:0.474,95%CI:0.303-0.743,P=0.743,P=0.001]were influencing factors for long-term survival of patients with cirrhosis complicated with EGVB after TIPS treatment.Conclusion:Transjugular intrahepatic portosystemic shunt can effectively reduce portal hypertension and is an effective and safe method for the treatment of HCC complicated with EGVB.