摘要
目的:探讨胰十二指肠切除术后出血(PPH)的危险因素及治疗策略。方法:采用回顾性病例对照研究方法。收集2012年1月至2021年11月北京大学第一医院收治的712例行胰十二指肠切除术患者的临床资料;男392例,女320例;中位年龄为62岁,年龄范围为16~89岁。观察指标:(1)PPH诊断情况。(2)PPH影响因素分析。(3)PPH治疗情况。偏态分布的计量资料以M(范围)表示。计数资料以绝对数或百分比表示。单因素分析采用χ^(2)检验或Fisher确切概率法,多因素分析采用Logistic回归模型。结果:(1)PPH诊断情况。712例患者中,72例发生PPH,其中7例死亡。PPH发生率为10.11%(72/712),PPH相关病死率为9.72%(7/72)。72例患者中,早期PPH 7例,晚期PPH 65例;轻度PPH 23例,重度PPH 49例。(2)PPH影响因素分析。单因素分析结果显示:术前血清总胆红素(TBil)、扩大切除、术后胰瘘、术后胆瘘、术后腹腔感染是影响晚期PPH的相关因素(χ^(2)=13.17,3.93,87.89,22.77,36.13,P<0.05)。多因素分析结果显示:术前血清TBil≥171μmol/L、术后胰瘘为B级或C级、术后胆瘘、术后腹腔感染是影响晚期PPH的独立危险因素(优势比=1.91,8.10,2.11,2.42,95%可信区间为1.09~3.33,4.62~14.20,1.06~4.23,1.35~4.31,P<0.05)。(3)PPH治疗情况。①早期PPH治疗:7例早期PPH患者中,轻度PPH 4例,重度PPH 3例。4例轻度PPH患者经保守治疗成功止血。3例重度PPH患者的出血部位分别为胰肠吻合口后壁、胰腺钩突残端、空肠营养管穿刺腹壁导致左季肋区腹壁血管副损伤,均经再次手术成功止血。7例早期PPH患者均无其他并发症,顺利出院。②晚期PPH治疗:65例晚期PPH患者中,轻度PPH 19例,重度PPH 46例。19例轻度PPH患者中,18例行保守治疗成功止血(其中2例死于胰瘘和腹腔感染),1例行内镜治疗成功止血。46例重度PPH患者中,18例生命体征稳定、出血速度缓慢者行保守治疗成功止血(其中1例死于感染中毒性休克);28例行有创治疗,首选内镜治疗2例,首选介入治疗20例,首选二次手术治疗6例。22例首选内镜及介入治疗患者中,5例再出血,2例死亡,再出血率和病死率分别为22.7%(5/22)和9.1%(2/22);6例首选二次手术治疗患者中,3例再出血,2例死亡,再出血率和病死率分别为3/6和2/6;两者再出血率和病死率比较,差异均无统计学意义(P>0.05)。28例行有创治疗患者中,10例行二次手术治疗(首选手术治疗6例、首选介入治疗再出血4例),死亡4例,病死率为4/10;18例未行二次手术治疗患者均生存;两者病死率比较,差异有统计学意义(P<0.05)。结论:术前血清TBil≥171μmol/L、术后胰瘘为B级或C级、术后胆瘘、术后腹腔感染是影响晚期PPH的独立危险因素。早期重度PPH应果断手术止血。晚期重度PPH保守治疗无效者,首选内镜治疗或介入治疗止血,若上述措施无效,可行手术治疗。
Objective:To investigate the risk factors and treatment of postpancreatico-duodenectomy hemorrhage(PPH).Methods:The retrospective case-control study was conducted.The clinical data of 712 patients who underwent pancreaticoduodenectomy in Peking University First Hospital from January 2012 to November 2021 were collected.There were 392 males and 320 females,aged from 16 to 89 years,with a median age of 62 years.Observation indicators:(1)diagnosis of PPH;(2)analysis of influencing factors for PPH;(3)treatment of PPH.Measurement data with skewed distribution were represented as M(range).Count data were described as absolute numbers or percentages.Univariate analysis was performed using the chi-square test or Fisher exact probability,and multivariate analysis was performed using the Logistic regression model.Results:(1)Diagnosis of PPH.Of the 712 patients,72 cases had PPH and 7 cases died.The incidence of PPH was 10.11%(72/712),and PPH related mortality was 9.72%(7/72).There were 7 cases of early PPH and 65 cases of delayed PPH.There were 23 cases of mild PPH and 49 cases of severe PPH.(2)Analysis of influencing factors for PPH.Results of univariate analysis showed that preoperative serum total bilirubin(TBil),extended surgery,postoperative pancreatic fistula,postoperative biliary fistula,postoperative abdominal infection were related factors for delayed PPH(χ^(2)=13.17,3.93,87.89,22.77,36.13,P<0.05).Results of multivariate analysis showed that preoperative serum TBil≥171μmol/L,postoperative grade B or C pancreatic fistula,postoperative biliary fistula,postoperative abdominal infection were independent risk factors for delayed PPH(odds ratio=1.91,8.10,2.11,2.42,95%confidence interval as 1.09-3.33,4.62-14.20,1.06-4.23,1.35-4.31,P<0.05).(3)Treatment of PPH.①Treatment of early PPH.Of the 7 cases with early PPH,4 cases had mild PPH and 3 cases had severe PPH.The 4 cases with mild PPH were stanched by conservative treatment.The bleeding location of the 3 cases with severe PPH were the posterior wall of pancreatoenteric anastomosis,the pancreatic uncinate stump and the unintentional puncture of the jejunostomy tube of the left upper abdominal wall vessels and the 3 cases were stanched by reoperation.All the 7 cases were discharged without other complications.②Treatment of delayed PPH.Of the 65 cases with delayed PPH,19 cases had mild PPH and 46 cases had severe PPH.Of the 19 cases with mild PPH,18 cases were stanched by conservative treatment including 2 cases died of pancreatic fistula and abdominal infection,1 case were stanched by endoscope therapy.Of the 46 cases with severe PPH,18 cases with stable vital signs and slow bleeding were stanched by conservative treatment including 1 case died of infectious toxic shock and the other 28 cases underwent invasive treatment,including 2 cases undergoing gastroscopy,20 cases undergoing interventional treatment and 6 cases under-going reoperation as the initial treatment.Of the 22 cases taking endoscope or interventional treatment as the initial treatment,5 cases underwent rebleeding and 2 cases died,with the reblee-ding rate and mortality as 22.7%(5/22)and 9.1%(2/22),respectively.Of the 6 cases taking reopera-tion as the initial treatment,3 cases underwent rebleeding and 2 cases died,with the rebleeding rate and mortality as 3/6 and 2/6,respectively.There was no significant difference in the rebleeding rate and mortality in patients taking endoscope or interventional treatment as the initial treatment and patients taking reoperation as the initial treatment(P>0.05).Of the 28 cases undergoing invasive treatment,10 cases underwent secondary surgical treatment,including 6 cases taking reoperation and 4 cases taking interventional treatment as the initial treatment for hemorrhage,and 4 cases died with the mortality as 4/10,and the other 18 cases who did not receive secondary surgical treatment survived.There was a significant difference in the mortality between patients with or without secondary surgical treatment(P<0.05).Conclusions:Preoperative serum TBil≥171μmol/L,post-operative grade B or C pancreatic fistula,postoperative biliary fistula,postoperative abdominal infection are independent risk factors for delayed PPH.Surgical treatment should be performed decisively for early severe PPH.For delayed severe PPH patients who undergoing conservative treat-ment without effect,endoscope therapy and interventional treatment should be the first choice,and surgical treatment should be performed if those above procedures not working.
作者
高红桥
李宝毅
马永蔌
田孝东
庄岩
杨尹默
Gao Hongqiao;Li Baoyi;Ma Yongsu;Tian Xiaodong;Zhuang Yan;Yang Yinmo(Department of General Surgery,Peking University First Hospital,Beijing 100034,China)
出处
《中华消化外科杂志》
CAS
CSCD
北大核心
2022年第4期492-499,共8页
Chinese Journal of Digestive Surgery
基金
国家自然科学基金(82171722)。
关键词
胰腺肿瘤
胰十二指肠切除术
术后出血
胰瘘
并发症
外科手术
手术
诊断
治疗
Pancreatic neoplasms
Pancreaticoduodenectomy
Postoperative hemorrhage
Pancreatic fistula
Complication
Surgical procedures,operative
Operation
Diagnosis
Treatment
作者简介
通信作者:杨尹默,Email:yangyinmo@263.net。
