腹腔镜胰十二指肠切除术后出血的原因及对策

Hemorrhage after laparoscopic pancreaticoduodenectomy: causes and countermeasures

目的探讨腹腔镜胰十二指肠切除术(LPD)术后出血的原因及对策。方法回顾性分析2013年12月至2020年5月期间在浙江省人民医院肝胆胰外科行LPD的215例患者的临床资料。记录患者的性别、年龄、合并症、术后并发症(出血、胰瘘、胆瘘、腹腔感染)等临床资料,分析胰腺切除术后出血(PPH)的原因、临床表现及治疗方法。结果纳入215例患者中男性132例,女性83例,年龄(60.7±10.3)岁,术后共发生20例PPH,发生率为9.30%(20/215)。早期出血主要原因为止血不确切和血管夹脱落;晚期出血主要原因为消化道瘘、术中能量电外科器械动脉损伤及假性动脉瘤。20例PPH患者中,早期出血6例,迟发性出血14例;A级出血患者1例,B级出血患者10例,C级出血患者9例;胰瘘13例,胆瘘1例,腹腔感染2例。保守治疗成功1例;胃镜下成功止血1例;数字减影血管造影(DSA)17例,介入治疗成功止血7例;11例患者行剖腹探查。20例PPH患者中,14例治愈出院,6例死亡,死亡率30.0%(6/20)。结论早期出血与止血不确切和血管夹脱落相关;晚期出血与消化道瘘、术中能量器械动脉损伤及假性动脉瘤相关。LPD术中应精细止血保护好血管、精准吻合以提高消化道重建的质量。PPH"治疗窗"很窄,对不能排除动脉性出血者应选择DSA栓塞或放置覆膜支架,对介入治疗失败的B/C级出血者应果断手术探查,从而降低患者的病死率。

Objective To study the causes of hemorrhage after laparoscopic pancreaticoduodenectomy(LPD)and to develop countermeasures in its prevention.Methods The clinical data of 215 patients who underwent LPD at the Department of Hepatobiliary and Pancreatic Surgery of Zhejiang Provincial People's Hospital from December 2013 to May 2020 were reviewed.The patients’clinical data including gender,age,comorbidities and postoperative complications such as bleeding,pancreatic fistula,biliary fistula and intraperitoneal infection were studied,with the aims to analyze the causes,clinical manifestations and treatment results of post-pancreaticoduodenectomy hemorrhage(PPH)after LPD.Results Of 215 patients,there were 132 males and 83 females,aged(60.7±10.3)years.PPH occurred in 20 patients,incidence rate was 9.30%(20/215).Early hemorrhage was mainly caused by inadequate hemostasis or loosening of vascular clips,while delayed hemorrhage was mainly caused by gastrointestinal fistula with vascular erosion,arterial injury by intraoperative energy instruments or pseudoaneurysms.Among the 20 patients,6 patients had early hemorrhage and 14 delayed hemorrhage.There was 1 patient with grade A,10 with grade B and 9 with grade C hemorrhage.Thirteen patients developed pancreatic fistula,1 biliary fistula,and 2 intraperitoneal infection.One patient responded well to conservative treatment.Hemostasis was successfully achieved by gastroscopy(n=1)and interventional therapy(n=7).Eleven patients required laparotomy for hemostasis.In this study,14 of 20 patients survivied PPH and 6 patients died.The mortality rate was 30%(6 of 20 patients with PPH).Conclusions Early hemorrhage was caused by inadequate hemostasis or loosening vascular clips,while delayed hemorrhage was related to gastrointestinal fistula with vascular erosion,arterial injury by intraoperative energy instrument or pseudoaneurysm.Careful hemostasis,adequate protection of blood vessels,and accurate anastomosis should be performed in LPD.DSA angiography should be used for arterial hemorrhage which progressed very rapidly.Interventional therapy including embolism and stenting were means to control arterial bleeding in PPH.Decisive surgical exploration when interventional therapy failed was important in reducing the mortality rate of these patients.