胰十二指肠切除术后门静脉系统严重出血诊断与治疗

doi:10.3877/cma.j.issn.2095-3232.2018.06.012

目的

探讨胰十二指肠切除术（PD）后门静脉系统严重出血的诊断与治疗。

方法

回顾性分析2000年1月至2017年12月在解放军总医院诊治的6例PD后门静脉系统严重出血患者临床资料。患者均为男性；50～70岁，中位年龄56岁。患者均签署知情同意书，符合医学伦理学规定。原发病：胆管下段癌、胰头导管腺癌各2例，十二指肠癌、十二指肠乳头癌各1例。3例患者行保留幽门的PD，3例行经典的PD。

结果

同期完成的2 149例PD，术后6例发生门静脉系统出血，发生率0.28%。门静脉出血发生在PD后6～38 d，中位时间20 d。6例患者均合并胰瘘，表现为腹腔出血或便血。再次手术或血管造影检查证实的门静脉或肠系膜上静脉出血。3例接受门静脉覆膜支架置入治疗，3例接受再次手术治疗。术后存活4例，2例死于失血性休克。

结论

PD后门静脉系统大出血较为少见，诊断依靠临床表现、手术探查和血管造影，治疗可采用手术缝合和介入治疗，其中门静脉覆膜支架置入术目前被证实是安全有效的治疗手段，可作为此类并发症的首选治疗方案。

关键词: 胰十二指肠切除术, 门静脉, 出血, 胰腺瘘, 放射学，介入性

Objective

To investigate the diagnosis and treatment for severe hemorrhage of portal vein system after pancreaticoduodenectomy (PD).

Methods

Clinical data of 6 patients with severe portal vein hemorrhage after PD in Chinese PLA General Hospital from January 2000 to December 2017 were retrospectively analyzed. All patients were male, aged 50-70 years with a median age of 56 years. The informed consents of all patients were obtained and the local ethical committee approval was received. The primary diseases were 2 cases of distal bile duct carcinoma, 2 cases of pancreatic head ductal adenocarcinoma, 1 case of duodenal carcinoma and 1 case of duodenal papilla carcinoma. 3 patients underwent pylorus-preserving PD and 3 underwent classic PD.

Results

Among the 2 149 cases undergoing PD, 6 suffered from portal vein system hemorrhage after operation with an incidence of 0.28%. Portal vein hemorrhage occurred from 6 to 38 d after PD with a median of 20 d. All 6 cases were complicated with pancreatic fistula, with symptom of abdominal bleeding or hematochezia. Portal vein or superior mesenteric vein hemorrhage was confirmed by reoperation or angiography. 3 patients received portal vein stent implantation and3 underwent reoperation. After operation, 4 cases survived and 2 died of hemorrhagic shock.

Conclusions

Massive portal vein system hemorrhage after PD is rare. Its diagnosis depends on clinical manifestations, surgical exploration and angiography. The treatments include surgical suture and interventional therapy. Portal vein stent implantation has been proven a safe and effective treatment and can be the preferred alternative treatment for the complication.

Key words: Pancreaticoduodenectomy, Portal vein, Hemorrhage, Pancreatic fistula, Radiology, interventional

图1 一例胰十二指肠切除术后门静脉出血患者血管造影图像

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