摘要
目的 分析远端胰腺切除术（DP）术后迟发性出血（DPPH）的临床特征、诊断及治疗转归，以指导临床决策。方法 回顾性分析2018年7月至2023年12月浙江大学医学院附属第一医院肝胆胰外科收治的63例DP术后发生DPPH病人的临床资料。依据国际胰腺外科研究小组的胰腺术后出血分级标准进行分组：B级DPPH 29例（ISGPS-B组），C级DPPH 34例（ISGPS-C组）。评估其相关风险因素、临床特征及诊疗策略。结果 63例病人中行保留脾脏的DP 22例（Kimura术19例、Warshaw术3例），行联合脾脏切除的DP 41例。DPPH相关死亡5例（7.9%）。C级DPPH伴有前哨出血21例（61.8%）。ISGPS-C组临床相关胰瘘及腹腔感染发生率高于ISGPS-B组，差异有统计学意义（94.1% vs. 75.9%，P=0.039；55.9% vs. 24.1%，P=0.020）。34例（54.0%）DPPH的出血部位得到明确定位，主要为胃十二指肠动脉（7例）、脾动脉（6例）、门静脉系统（6例）等。增强CT及数字减影血管造影（DSA）对出血的定位成功率分别为31.0%（13/42）及60.9% （14/23），差异有统计学意义（P=0.019）。DSA下血管介入栓塞的止血成功率为80.0%（12/15），再手术的止血成功率为69.2%（18/26），差异无统计学意义（P=0.716）。3例DPPH（1例脾动脉残端出血、2例腹腔干出血）行DSA下腹腔干介入栓塞，术中造影检查均提示肝动脉血供良好，术后病人恢复顺利。结论 胃十二指肠动脉是DP术后出血的常见部位之一，术中须重视保护；DSA可作为DP术后DPPH的首选诊断及治疗策略。
Abstract
To analyze the clinical characteristics, diagnostic approaches, and therapeutic outcomes of delayed post-pancreatectomy hemorrhage (DPPH) following distal pancreatectomy (DP), in order to guide clinical decision-making. Methods A retrospective review based on the clinical data of 63 patients who developed DPPH after DP between July 2018 and December 2023 at our center was conducted. According to the International Study Group for Pancreatic Surgery (ISGPS) classification, 29 cases were grade B (ISGPS-B group) and 34 were grade C (ISGPS-C group). Relevant risk factors, clinical features, and management strategies of DPPH were evaluated. Results Of these, 22 underwent spleen-preserving DP (Kimura, n=19; Warshaw, n=3) and 41 underwent DP with splenectomy. Five patients (7.9%) died from DPPH-related causes. Sentinel bleeding was observed in 21 grade C cases (61.8%). The incidence rate of clinically relevant pancreatic fistula and intra-abdominal infections in the ISGPS-C group was higher than that in the ISGPS-B group, and the difference was statistically significant (94.1% vs. 75.9%, P=0.039; 55.9% vs. 24.1%, P=0.020). The bleeding site was clearly localized in 34 cases (54.0%), with the gastroduodenal artery (n=7), splenic artery (n=6), and portal venous system (n=6) being the most common. The localization rates of contrast-enhanced CT and digital subtraction angiography (DSA) were 31.0% (13/42) and 60.9% (14/23), respectively (P=0.019). Hemostasis success rates were 80.0% (12/15) for endovascular embolization under DSA and 69.2% (18/26) for reoperation (P=0.716). In three cases of DPPH (one splenic artery stump hemorrhage and two celiac trunk hemorrhages), selective embolization of the celiac trunk was performed under DSA, with intraoperative angiography confirming adequate hepatic arterial supply, and all patients recovered uneventfully. Conclusion The gastroduodenal artery is a common bleeding site after DP. DSA provides higher localization accuracy and therapeutic efficacy, and should be considered the preferred diagnostic and therapeutic strategy for DPPH following DP.
关键词
远端胰腺切除术 /
术后迟发性出血 /
数字减影血管造影 /
再手术
Key words
distal pancreatectomy /
delayed postpancreatectomy hemorrhage /
digital subtraction angiography /
relaparotomy
林暐乔1, 钱 涛1, 李慧亮1, 刘子葳1, 高顺良1, 白雪莉1, 马 涛1, 2, 梁廷波1.
远端胰腺切除术后迟发性出血临床特点及诊疗策略单中心研究[J]. 中国实用外科杂志. 2025, 45(10): 1148-1154 https://doi.org/10.19538/j.cjps.issn1005-2208.2025.10.15
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