胰十二指肠切除术后晚期出血的诊断与治疗
이십이지장절제술후만기출혈적진단여치료
Diagnosis and treatment of delayed postoperative hemorrhage after pancreaticoduodenectomy
  • 万方数据
    中华消化外科杂志 중화소화외과잡지
    CHINESE JOURNAL OF DIGESTIVE SURGERY
    2014年 4期 277-280 ,共4页

    王正堂%林海%王勇%苏力担卡扎·仇曼%何铁英%韩玮%温浩%陈启龙

    왕정당%림해%왕용%소력담잡찰·구만%하철영%한위%온호%진계룡

    胰十二指肠切除术%手术后出血%诊断%治疗 胰十二指腸切除術%手術後齣血%診斷%治療
    이십이지장절제술%수술후출혈%진단%치료
    Pancreaticoduodenectomy%Postoperative hemorrhage%Diagnosis%Treatment
    目的 总结胰十二指肠切除术后晚期出血的诊断与治疗经验.方法 回顾性分析2002年1月至2013年2月新疆医科大学第一附属医院收治的246例行胰十二指肠切除术患者的临床资料.胰头及壶腹部恶性肿瘤行标准胰十二指肠切除术或联合脏器切除,良性肿瘤及十二指肠乳头肿瘤行保留幽门的胰十二指肠切除术.消化道吻合采用胰肠或胰胃吻合两种方式.患者术后出血时间＞5d定义为晚期出血.消化道出血为消化道出血组,腹腔出血为腹腔出血组.按出血程度分为轻度和重度出血.采取保守治疗和手术治疗(包括介入和开腹手术治疗)两种方法治疗晚期出血.计数资料组间比较采用Fisher确切概率法.结果 246例患者中行标准胰十二指肠切除术224例,行保留幽门的胰十二指肠切除术10例,行胰十二指肠切除联合门静脉切除或置换术9例,行胰十二指肠切除联合肠系膜上静脉置换术1例,行胰十二指肠切除联合肝方叶切除术1例,行胰十二指肠切除联合左半肝切除术1例.246例患者中行改良胰肠端侧吻合127例,行胰胃套入吻合53例,行传统胰肠端端套入吻合39例,行胰管空肠黏膜对黏膜吻合27例.患者围手术期死亡15例,病死率为6.10％ (15/246).术后29例患者发生晚期出血,出血发生率为11.79％ (29/246).其中消化道出血14例,腹腔出血15例.29例出血患者中轻度出血9例(消化道出血5例、腹腔出血4例);重度出血20例(消化道出血9例、腹腔出血11例).17例患者术后发生先兆出血,其中消化道出血5例、腹腔出血12例.29例患者均经常规保守治疗,消化道出血组患者保守治疗成功率为8/14,腹腔出血组为2/15,两组比较,差异有统计学意义(P＜0.05).保守治疗失败患者均中转手术治疗.20例重度出血患者中行手术治疗19例,1例经保守治疗成功.9例轻度出血患者全部行保守治疗,1例因肺部感染死亡,其余均获治愈.29例术后晚期出血患者中死亡10例,病死率为34.5％(10/29).消化道出血组患者病死率为2/14,腹腔出血组为8/15,两组比较,差异无统计学意义(P＞0.05).结论 胰十二指肠切除术后晚期出血常有先兆出血征象,出血程度多为重度.消化道出血经保守治疗多可治愈,腹腔出血需积极手术治疗.
    목적 총결이십이지장절제술후만기출혈적진단여치료경험.방법 회고성분석2002년1월지2013년2월신강의과대학제일부속의원수치적246례행이십이지장절제술환자적림상자료.이두급호복부악성종류행표준이십이지장절제술혹연합장기절제,량성종류급십이지장유두종류행보류유문적이십이지장절제술.소화도문합채용이장혹이위문합량충방식.환자술후출혈시간＞5d정의위만기출혈.소화도출혈위소화도출혈조,복강출혈위복강출혈조.안출혈정도분위경도화중도출혈.채취보수치료화수술치료(포괄개입화개복수술치료)량충방법치료만기출혈.계수자료조간비교채용Fisher학절개솔법.결과 246례환자중행표준이십이지장절제술224례,행보류유문적이십이지장절제술10례,행이십이지장절제연합문정맥절제혹치환술9례,행이십이지장절제연합장계막상정맥치환술1례,행이십이지장절제연합간방협절제술1례,행이십이지장절제연합좌반간절제술1례.246례환자중행개량이장단측문합127례,행이위투입문합53례,행전통이장단단투입문합39례,행이관공장점막대점막문합27례.환자위수술기사망15례,병사솔위6.10％ (15/246).술후29례환자발생만기출혈,출혈발생솔위11.79％ (29/246).기중소화도출혈14례,복강출혈15례.29례출혈환자중경도출혈9례(소화도출혈5례、복강출혈4례);중도출혈20례(소화도출혈9례、복강출혈11례).17례환자술후발생선조출혈,기중소화도출혈5례、복강출혈12례.29례환자균경상규보수치료,소화도출혈조환자보수치료성공솔위8/14,복강출혈조위2/15,량조비교,차이유통계학의의(P＜0.05).보수치료실패환자균중전수술치료.20례중도출혈환자중행수술치료19례,1례경보수치료성공.9례경도출혈환자전부행보수치료,1례인폐부감염사망,기여균획치유.29례술후만기출혈환자중사망10례,병사솔위34.5％(10/29).소화도출혈조환자병사솔위2/14,복강출혈조위8/15,량조비교,차이무통계학의의(P＞0.05).결론 이십이지장절제술후만기출혈상유선조출혈정상,출혈정도다위중도.소화도출혈경보수치료다가치유,복강출혈수적겁수술치료.
    Objective To summarize the clinical experience in the diagnosis and treatment of delayed postoperative hemorrhage after pancreaticoduodenectomy.Methods The clinical data of 246 patients who received pancreaticoduodenectomy at the First Affiliated Hospital of Xinjiang Medical University from January 2002 to February 2013 were retrospectively analyzed.Patients with pancreatic head carcinoma and ampullary malignancies received standard pancreaticoduodenectomy or combined organ resection,and patients with benign and duodenal tumor received pylorus-preserving pancreaticoduodenectomy.Pancreatic anastomosis was done using pancreaticogastrostomy or pancreaticojejunostomy.Delayed hemorrhage was defined as bleeding at the operation site after 5 or more postoperative days.Patients were divided into the gastrointestinal hemorrhage group and the abdominal hemorrhage group according to the bleeding site,and the treatment methods included conservative treatment or surgical treatment (including interventional therapy and laparotomy).The Measurement data were expressed as mean ± standard deviation,and the enumeration data were compared using the Fisher exact probability.Results There were 224 patients received pancreaticoduodenectomy,10 received pylorus-preserving pancreaticoduodenectomy,9 received pancreatieoduodenectomy + portal vein resection or replacement,1 received pancreaticoduodenectomy + superior mesenteric vein replacement,1 received pancreaticoduodenectomy + resection of quadrate lobe of liver and 1 received pancreaticoduodenectomy + resection of left semihepatectomy.There were 127 patients received improved end-to-side pancreaticojejunostomy,53 received pancreaticogastrostomy,39 received end-to-end pancreaticojejunostomy and 27 received mucosa-to-mucosa pancreaticojejunostomy.Fifteen patients died perioperatively,with the mortality rate of 6.10％ (15/246).Twenty-nine patients were complicated with delayed hemorrhage with the rate of 11.79％ (29/246),including 14 with gastrointestinal hemorrhage and 15 with abdominal hemorrhage.There were 9 patients with mild hemorrhage (5 with gastrointestinal hemorrhage and 4 with abdominal hemorrhage) and 20 with severe hemorrhage (9 with gastrointestinal hemorrhage and 11 with abdominal hemorrhage).Seventeen patients had sentinel bleeding,including 5 with abdominal hemorrhage and 12 with gastrointestinal hemorrhage.Twenty-nine patients received conservative treatment,and the success rates of conservative treatment were 8/14 in the gastrointestinal hemorrhage group,which was significantly higher than 2/15 of the abdominal hemorrhage group (P ＜ 0.05).Patients who failed in conservative treatment received surgical treatment.Of the 20 patients with severe hemorrhage,19 were cured by surgical treatment and I was cured by conservative treatment.Nine patients with mild hemorrhage received conservative treatment,8 were cured and 1 died of pulmonary infection.Of the 29 patients with delayed postoperative hemorrhage,10 died with the mortality rate of 34.5％ (10/29).The morality rate of the gastrointestinal hemorrhage group was 2/14,which was lower than 8/15 of the abdominal hemorrhage group,with no significant difference between the 2 groups (P ＞ 0.05).Conclusions Most of the delayed postoperative hemorrhage after pancreaticoduodenectomy severe and combined with sentinel bleeding.Gastrointestinal hemorrhage can be cured through conservative treatment,but abdominal hemorrhage need surgical treatment.
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