胆胰术后迟发性出血介入治疗

Interventional treatment for delayed postoperative hemorrhage after biliary and pancreatic surgery

目的探讨胆胰术后迟发性出血介入治疗方法、技术和效果。方法总结海军军医大学东方肝胆外科医院2016年7月至2019年6月期间采用血管内介入术治疗74例胆胰外科术后迟发性出血患者的经验,对比不同介入治疗方法的效果,分析影响患者死亡的因素。结果 74例患者首次血管造影阳性率为90.5%(67/74),血管内介入治疗成功率为98.6%(73/74),死亡率为29.7%(22/74)。死亡主要原因为再出血15例(20.3%)、肝衰竭4例(5.4%)、感染2例(2.7%)、介入操作不成功1例(1.4%)。不同疾病诊断和手术方式间死亡率差异有统计学意义(P<0.05),肝门胆管癌患者死亡率较高。出血类型、出血动脉对术后迟发性出血患者死亡率均无明显影响(P>0.05)。非出血性并发症显著增加患者死亡率(P<0.001)。再出血患者死亡率显著高于无再出血患者(65.2%对12.0%,P<0.001)。覆膜支架植入患者死亡率(26.5%)低于栓塞治疗患者(30.8%),但差异无统计学意义(P>0.05)。结论血管内介入术是治疗胆胰术后迟发性出血的有效方法。需合理选择覆膜支架和栓塞方法。减少术后并发症、降低再出血是控制胆胰术后迟发性出血死亡率的关键。

Objective To discuss the method, technique and curative effect of interventional treatment for delayed postoperative hemorrhage after biliary and pancreatic surgery. Methods The medical experience in treating 74 patients with delayed postoperative hemorrhage after biliary and pancreatic surgery, who were treated with endovascular interventional therapy during the period from July 2016 to June 2019 at the Oriental Hepatobiliary Surgery Hospital of Naval Military Medical University of China, was summarized. The curative effects were compared between different interventional treatment methods and the factors affecting mortality were analyzed. Results In the 74 patients, the positive rate of initial angiography was 90.5%(67/74), the technical success rate of endovascular intervention was 98.6%(73/74), and the mortality was 29.7%(22/74).The main causes of death included rebleeding(n=15, 20.3%), hepatic failure(n= 4, 5.4%), infection(n=4,2.7%), and failure of interventional manipulation(n=1, 1.4%). There were statistically significant differences in mortality existed between patients with different disease diagnoses and between patients receiving different surgical procedures(P<0.05). In the patients with hepatohilar cholangiocarcinoma the mortality was the highest.The bleeding types and hemorrhagic arteries had no obvious effect on the mortality of patients with delayed postoperative hemorrhage after biliary and pancreatic surgery(P>0.05). The mortality in the patients who had rebleeding was remarkably higher than that in the patients who had no rebleeding(65.2% versus 12.0%,P<0.001). The mortality in the patients who received covered-stent implantation was 26.5%, which was lower than 30.8% in the patients who received embolization therapy, but the difference was not statistically significant(P>0.05). Conclusion For delayed postoperative hemorrhage after biliary and pancreatic surgery, endovascular intervention is an effective treatment. The covered-stent and embolization method should be reasonably selected. It is the key point to reduce postoperative complications and decrease rebleeding rate for controlling the mortality of delayed bleeding after biliary and pancreatic surgery.