胰十二指肠切除术后上消化道大出血的原因及对策

Cause and Treatment of Upper Gastrointestinal Hemorrhage after Pancreatoduodenectomy

目的探讨胰十二指肠切除术(PDT)后近期上消化道大出血(UGIH)的原因、诊断及治疗。方法对2000年1月至2007年12月期间华西医院普外科行PDT的192例患者临床资料进行回顾性分析,并对术后UGIH患者的出血时间、出血原因、诊断与治疗方法及结果进行探讨。结果PDT术后发生UGIH12例,其中早期(术后第1、2d)出血3例,晚期(术后第5d以后)出血9例,其中4例死亡。出血原因:应激性溃疡出血7例、胃肠吻合口出血3例、胰腺断面出血2例。术前胆红素水平以及术中输血量在术后出血组和未出血组间比较差异有统计学意义(P<0.05)。12例出血病例中6例行综合内科治疗,4例止血成功,2例死亡;6例行手术止血,4例止血成功,2例术后发生多器官功能衰竭而死亡。结论术前胆红素水平和术中输血量是术后发生UGIH的相关因素。早期出血以吻合口出血为主,应强调早期手术治疗的重要性;晚期出血以应激性溃疡为主,保守治疗多可止血。急诊胃镜和术中胃镜检查对出血部位的诊断及治疗具有非常重要的作用。

Objective To investigate the causes, diagnoses and principles of treatment of the upper gastrointestinal hemorrhage （UGIH） after pancreatoduodenectomy （PDT）. Methods One hundred and ninety-two patients who underwent PDT at West China hospital from January 2000 to December 2007 were retrospectively analyzed, and the causes of bleeding, treatments and outcomes of the patients who had postoperative gastrointestinal hemorrhage were investigated as well. Results UGIH occurred after PDT in 12 patients and 4 of them died. Three cases were early postoperative bleeding and nine cases were later bleeding. The causes of bleeding included bleeding from by anostomotic ulcer or stress ulcer （7 cases）, bleeding from gastroenterostomy site （3 cases） and two bleeding from pancreatic cut surface （2 cases）. The serum bilirubin level before operation and transfusion volume during operation were satistically different between the patients with or without UGIH （P〈0.05）. Of all the patients with UGIH, six cases were dealt with by internal medicine, four of them recovered and two died; while six cases were treated by immediate relaparotomy, four of them recovered and two died of multiple organ failure. Conclusion The serum bilirubin level before operation and the volume of transfusion during operation are the factors related to UGIH after PDT. Hemorrhage within 5 days after operation is mostly caused by gastroenterostomy and should be treated by immediate laparotomy. Hemorrhage occurred after 5 days is mainly due to anastomotic stress ulcer and most of them can be controlled by internal medicine. Emergercy and intraoperative gastrointestinal endoscopy plays an important role in diagnosing the bleeding site and controlling hemorrhage.