天津医药

• 临床论丛 •    

胰十二指肠切除术后中重度出血分析

卢诚军1,杜智1,王毅军1,袁强1,王军1,舒桂明1,卢诚震2   

  1. 1. 天津市第三中心医院
    2. 天津市传染病医院
  • 收稿日期:2011-05-03 修回日期:2011-09-27 出版日期:2012-03-15 发布日期:2012-03-15
  • 通讯作者: 杜智

The analyze for postpancreaticoduodenectomy severe hemorrhage

  • Received:2011-05-03 Revised:2011-09-27 Published:2012-03-15 Online:2012-03-15

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摘要： 摘要：目的 胰十二指肠切除术后出血（PPH）是极具威胁的并发症，并且由于病理生理和临床表现的多样性，很难确定完善的诊疗常规。笔者分析十年的诊疗经验，以期给予病人更为及时有效地治疗。方法 回顾性分析2000至2009年其间295例壶腹周围肿瘤实施胰十二指肠切除术的临床资料。以下几个影响因素被收集，PPH的严重程度（分为中度，血红蛋白浓度下降<30 g/L、重度，>30 g/L），出血发生时间（分为早期，术后5天内、延时，第6天以后），出血部位（胃肠道内或/和外），是否合并胰瘘及复杂的血管病变（如血管侵蚀、假性动脉瘤），治疗的成功率和与PPH相关的死亡率。结果 PPH发生率6.4%（n=19）。中度出血47.4%(n=9), 重度出血52.6%(n=10), 哨兵出血26.3%(n=5)。 胃肠道外出血21.1%(n=4)，胃肠道内73.6%(n=14)，?同时存在5.3% (n=1)。出血前已存在胰瘘31.6%(n=6)。 治疗成功率84.2%(n=16)，包括保守观察治疗5例，内镜下止血1例，介入栓塞5例，再手术5例。PPH相关死亡率15.8% (n =3)，与以下几个因素密切相关1)延时出血；2)存在胰瘘；3)存在血管病变，如血管侵蚀和假性动脉瘤。结论 早期PPH多与手术技术相关。延时PPH的发生与胰瘘的存在密切相关，也是最危险的死亡因素。治疗方式的决定应参考出血时间、出血部位、胰瘘存在与否等因素。

关键词: 胰十二指肠切除术, 出血, 胰瘘, 介入, 再手术

Abstract: Abstract: Object Although postpancreaticoduodenectomy hemorrhage (PPH) is the most lifethreatening complication following pancreatic surgery, standardized rules for its management do not exist. To analyze and study clinical courses and outcome of PPH after major pancreatic surgery. Methods Between 2000 and 2009, 295 patients operated on for periampullary neoplasia were included in a prospective database. A risk stratification of PPH according to the following parameters was performed: severity of PPH classified as mild (drop of hemoglobin concentration <30 g/L) or severe (>30 g/L), time of PPH occurrence (early, first to fifth postoperative day; delayed, after sixth day), coincident pancreatic fistula, intraluminal or extraluminal bleeding manifestation, and presence of “complex” vascular pathologies (erosions, pseudoaneurysms). Success rates of management were analyzed as well as PPH-related overall outcome. Results Prevalence of PPH was 6.4% (n=19). Mild PPH was 47.4%(n=9), Severe PPH was 52.6% (n=10), “Sentinel” bleed was 26.3%(n=5). Extraluminal PPH was 21.1%(n=4), Intraluminal PPH was 73.6%(n=14), Extraluminal and intralumina PPH was 5.3% (n=1). Pancreatic fistula prior to PPH was 31.6%(n=6). Treatment-related overall success rates were 84.2%(n=16), included observational monitoring 5, interventional endoscopy 1, interventional radiology 5, and relaparotomy 5. PPH-related overall mortality of 15.8% (n =3) was closely associated with 1) delayed PPH occurrence; 2) the occurrence of pancreatic fistula; and 3) vascular pathologies, ie, erosions and pseudoaneurysms. Conclusion Early PPH was mainly due to surgical technical failures. Prognosis of delayed PPH depends mainly on the presence of preceding pancreatic fistula. Decision making as to the indication for nonsurgical interventions or relaparotomy should consider time of onset, presence of pancreatic fistula, vascular pathologies.

Key words: postpancreaticoduodenectomy, hemorrhage, pancreatic fistula, interventional radiology, relaparotomy