数字减影血管造影对胰腺切除术后出血的诊断与介入治疗价值

Diagnosis and interventional treatment value of digital subtraction angiography for post pancreatectomyhemorrhage

目的探讨行DSA检查和经导管动脉栓塞术（TAE）对胰腺切除术后出血（PPH）的诊断与治疗价值，以及PPH严重程度的影响因素。方法采用回顾性病例对照研究方法。收集2009年8月至2016年11月复旦大学附属中山医院收治的20例PPH患者的临床病理资料。早期出血多积极行再次手术止血治疗；晚期出血在予保守治疗、患者生命体征平稳时考虑行DSA检查和TAE治疗。观察指标：（1）DSA检查情况：总例次、阳性率、出血部位。（2）TAE治疗情况：止血成功率、操作时间、术后并发症情况。（3）随访情况。（4）PPH严重程度影响因素分析。采用门诊和电话方式进行随访，了解患者出院后相关并发症发生情况。随访时间截至2017年4月。偏态分布的计量资料以肘（范围）表示。计数资料以率或百分比表示。采用Fisher确切概率法行单因素分析。结果（1）DSA检查情况：20例患者均行DSA检查，共行27例次，18例次见明确的造影剂外溢直接征象，DSA检查阳性率为66．7％（18／27）。18例次DSA检查阳性发现中，明确的出血部位：胃十二指肠动脉5例次（3例次为胃十二指肠动脉残端假性动脉瘤），肝总动脉4例次（3例次为肝总动脉假性动脉瘤），肠系膜上动脉3例次，脾动脉2例次，胃左动脉、胃右动脉、肝左动脉（为肝左动脉假性动脉瘤）、肠系膜下动脉各1例次。（2）TAE治疗情况：18例次DSA检查阳性发现中，15例次行TAE治疗，TAE止血成功率为13／15，5例次行手术治疗成功止血。15例次TAE治疗操作中位时间为30min，术后无发热、腹痛、黑便、转氨酶升高、肝脓肿等不良反应，1例行脾动脉栓塞患者术后出现脾脓肿，行穿刺引流术后康复。9例次DSA检查阴性发现中，8例次行保守治疗痊愈，1例次行手术治疗成功止血。20例患者均痊愈出院。（3）随访情况：20例患者均获得随访，随访时间为4～92个月，中位随访时间为24个月。随访期间，20例患者均恢复顺利，无远期并发症发生。（4）PPH严重程度影响因素分析：单因素分析结果显示：性别、年龄、术前血糖、术前合并黄疸、术前Alb、术前PT延长、保留幽门、术中放置胰管支架、胰腺手术时间、胰腺术中出血量、术中输血、肿瘤性质、术后并发胰瘘、出血时间均不是PPH严重程度的影响因素（P〉0．05）。结论DSA检查对PPH具有微创诊断价值，对DSA检查阳性发现患者，行TAE治疗对大部分患者安全有效。

Objective To investigate the diagnosis and treatment value of digital subtraction angiography （DSA） and transeatheter arterial embolization （TAE） for post panereateetomy hemorrhage （PPH） , and influen- cing factors of severity of PPH. Methods The retrospective case-control study was conducted. The elinicopatho- logical data of 20 patients with PPH who were admitted to the Zhongshan Hospital of Fudan University from August 2009 to November 2016 were collected. Patients with PPH in the early stage underwent reoperations for hemosta- sis; patients with PPH in the later stage received conservative treatment, and then DSA and TAE were considered when patients had the stable vital signs. Observation indicators ： （ 1 ） DSA situations ： overall times, positive rate and bleeding sites; （2） TAE situations ： successful rate of hemostasis, operating time and postoperative complica- tions; （3） follow-up situations; （4） influencing faetors analysis of severity of PPH. Follow-up using outpatient examination and telephone interview was performed to detect occurrence of complications after dischargingfrom hospital up to April 2017. Measurement data with skewed distribution were described as M （range）. Count data were evaluated by the ratio and proportion. The univariate analysis was done using the Fisher exact probability. Results （ 1 ） DSA situations ： all the 20 patients underwent DSA, with overall times of 27. The direct sign was 18 times extravasation of the contrast medium, with a positive rate of 66.7% （18/27）. Of 18 times positive DSA, clear bleeding sites were located in 5 times gastroduodenal artery （ 3 times with pseudoaneurysm of gastroduodenal artery stump）, in 4 times common hepatic artery （3 times with pseudoaneurysm of common hepatic artery）, in 3 times superior mesenteric artery, in 2 times splenic artery, in 1 time left gastric artery, in 1 time right gastric artery, in 1 time left hepatic artery （pseudoaneurysm of left hepatic artery） and in 1 time inferior mesenteric artery. （2） TAE situations： of patients with 18 times positive DSA, patients with 15 times positive DSA received TAE, with a successful rate of hemostasis of 13/15, and patients with 5 times positive DSA received successful hemostasis by reoperation. A median operating time of TAE for patients with 15 times positive DSA was 30 minutes. There was no occurrence of adverse reaction, including fever, abdominal pain, melena, elevated aminotransferase and liver abscess. One patient complicated with splenic abscess after transcatheter splenic arterial embolization underwent puncture drainage and then had a good recovery. Of patients with 9 times negative DSA, patients with 8 times negative DSA were cured by conservative treatment and patient with 1 time negative DSA received successful hemostasis by operation. All the 20 patients were cured and then discharged from hospital. （3） Follow-up situations ： 20 patients were followed up for 4-92 months, with a median time of 24 months. During the follow-up, 20 patients recovered well, without long-term complications. （4） Influencing factors analysis of severity of PPH： the results of univariate analysis showed that gender, age, preoperative blood sugar, preoperative combined jaundice, preoperative albumin （Alb）, preoperative prothrombin time （PT） extended, preserving pylorus, pancreatic duct stent placement, pancreatic operation time, volume of intraoperative blood loss, intraoperative blood transfusion, property of tumor, postoperative pancreatic fistula and time of PPH were not factors affecting the severity of PPH （P〉0.05）. Conclusion DSA is minimal-invasive in the diagnosis for PPH, and TAE is safe and effective for patients with positive DSA.