医源性胆道大出血的介入治疗体会

Clinical value of interventional diagnosis and therapy of iatrogenic massive hemobilia

目的探讨医源性胆道大出血临床特点和介入诊治价值。方法回顾2018年7月至2022年6月期间收治的16例接受介入治疗的医源性胆道大出血患者临床资料,分析其出血原因及诊治过程,包括经导管数字减影血管造影技术(digital subtraction angiography,DSA)、引流管更换和调管、动脉栓塞及覆膜支架植入治疗。并分析所有患者的临床表现、实验室检查及DSA造影表现,评价其疗效和安全性。结果纳入16例患者,经皮肝穿刺胆道引流术后出血11例;胆道相关手术史4例,包括肝胰外伤修补术、肝移植术、胆管探查T管引流术和胰腺坏死组织清除术各1例;经内镜逆行胰胆管造影术后1例。出血部位为门静脉出血7例,肝动脉出血7例,恶性肿瘤慢性渗血2例。动脉出血者1例行肝动脉覆膜支架植入术,余6例均选择肝动脉栓塞术;门静脉出血者5例为调整引流管位置,2例更换引流管压迫止血,肿瘤渗血2例行经验性栓塞。预后技术成功率为14/16(87.5%),90 d生存率13/16(81.3%)。结论医源性损伤胆道大出血发病急骤、病情危重,介入治疗可快速诊断、治疗安全有效。

Objective To explore the clinical characteristics,interventional diagnostic and therapeutic value of iatrogenic biliary hemorrhage.Methods The clinical characteristics of 16 patients with iatrogenic massive biliary bleeding who received interventional treatment between July 2018 and June 2022 were reviewed.The clinical manifestations,laboratory examinations and digital subtraction angiography(DSA)findings of all patients were analyzed.The efficacy and safety were evaluated,using interventional therapy including replacement and adjustment of drainage tube,arterial embolization and stent-graft implantation for hemostasis.Results Eleven of 16 patients had bleeding after PTBD,accounting for 68.8%.4 hemorrhage cases had histories of biliary-related surgery(25.0%),including 1 case of hepatopancreatic trauma repair,1 case of liver transplantation,1 case of bile duct exploration and T-tube drainage,and 1 case of pancreatic necrotic tissue removal,and 1 hemorrhage case occurred after ERCP therapy(6.2%).The bleeding sites origin from portal vein bleeding in 7 cases,hepatic artery in 7 cases,and chronic bleeding of malignant tumor in 2 cases.Of the 7 hepatic artery bleeding cases,stent-graft implantation of hepatic artery was performed in 1 case,and hepatic artery embolization was performed in the other 6 cases.Of the 7 portal vein bleeding cases,the position of the drainage tube was adjusted in 5 cases,replacement of the drainage tube for the other 2 cases for compression hemostasis.At last,2 cases with chronic tumor bleeding who were underwent empirical embolization.The technique success rate was 14/16(87.5%),and the survival rate of 90 days was 13/16(81.3%).Conclusions Iatrogenic biliary hemorrhage usually is sudden onset and fatal.Interventional therapy was proved as a quickly diagnosis and serves as safely and efficiency methods for hemostasis.