介入治疗在腹部外科术后前哨出血中的应用探究

Application of interventional therapy in sentinel hemorrhage after abdominal surgery

目的评估数字减影血管造影(DSA)作为腹部外科术后前哨出血患者初始诊断工具的有效性和介入治疗在此类疾病中的临床应用价值。方法收集2018年7月至2020年11月我科诊治的45例腹部外科术后前哨出血患者的病例资料,回顾性分析其DSA造影结果及介入治疗疗效。结果DSA首次血管造影发现45例患者中,31例表现为对比剂外溢20例、假性动脉瘤6例和间接出血征象5例,阳性率为68.9%(31/45);其余14例首次血管造影阴性的患者中有6例出现迟发性出血,随后行DSA造影显示对比剂外溢2例,假性动脉瘤1例,动脉管壁不光整3例;8例未再出血经保守治疗后好转。DSA造影发现有出血征象的37例患者中有4例因腹腔感染行外科手术,其余33例患者均首选血管腔内治疗,其中2例因介入术中止血困难转外科手术,技术成功率为93.9%(31/33)。31例患者中有24例仅行介入治疗后取得临床成功,临床成功率为77.4%(24/31)。7例患者介入治疗后发生再出血,其中4例经重复栓塞后止血成功,3例介入止血失败转外科手术。单纯介入治疗组死亡率为17.6%(5/28),外科手术死亡率为55.5%(5/9),P=0.041。结论DSA可作为腹部外科术后前哨出血患者的一线诊断工具,在血管造影的基础上选择恰当的介入治疗对降低腹部外科术后迟发性大出血患者的死亡率具有重要的临床价值。

Objective To evaluate the effectiveness of DSA as an initial diagnostic tool for patients with sentinel hemorrhage after abdominal surgery and the clinical value of interventional therapy in such diseases.Methods The data of 45 patients with postoperative bleeding after abdominal surgery in our department from July 2018 to December 2020 were collected.The results of DSA and interventional therapy were analyzed retrospectively.Results Among the 45 patients detected by DSA for the first time,the 14 patients showed negative angiography and the other 31 cases showed contrast extravasation(n=20),pseudoaneurysm(n=6),irregular arterial wall and disordered distal branches(n=5),with a positive rate of 68.9%(31/45).Among the other 14 patients with negative angiography for the first time,the delayed hemorrhage occurred in 6 cases whose subsequent DSA showed contrast extravasation in 2 cases,pseudoaneurysm in 1 case,uneven arterial wall in 3 cases,and 8 cases without rebleeding were improved after conservative treatment.Among the 37 patients with signs of bleeding found by DSA,4 patients underwent surgery because of abdominal infection,while the other 33 patients preferred endovascular treatment,of whom 2 cases were converted to surgery because of hemostasis difficulties during interventional operation,resulting in a technical success rate of 93.9%(31/33).Among the 31 patients,24 patients achieved clinical success only by interventional therapy,with a clinical success rate of 77.4%(24/31).Rebleeding occurred in 7 patients after interventional therapy,of which 4 cases were successfully stopped by repeated embolization,and 3 failed cases were converted to surgery.The mortality rate was 17.6%(5/28)in the interventional therapy group,and 55.5%(5/9)in the surgical mortality,P=0.041.Conclusions DSA can be used as a first-line diagnostic tool for patients with sentinel hemorrhage after abdominal surgery.Choosing appropriate interventional therapy on the basis of angiography has important clinical value in reducing the mortality of patients with delayed massive hemorrhage after abdominal surgery.