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中华介入放射学电子杂志

中华介入放射学电子杂志 ›› 2024, Vol. 12 ›› Issue (01) : 39 -44. doi: 10.3877/cma.j.issn.2095-5782.2024.01.007

血管介入

介入治疗胃胆胰术后迟发性出血的临床疗效与安全性
陈涛1, 石红建1, 周良1, 甘振1,†()   
  1. 1. 210011　江苏南京，南京医科大学第二附属医院介入血管外科
  • 收稿日期:2023-07-24 出版日期:2024-02-25
  • 通信作者: 甘振

Interventional treatment for delayed postoperative hemorrhage after gastric and pancreatic-biliary surgery

Tao Chen1, Hongjian Shi1, Liang Zhou1, Zhen Gan1,†()   

  1. 1. Department of Interventional Radiology and Vascular Surgery, Second Affiliated Hospital of Nanjing Medical University, Jiangsu Nanjing 210011, China
  • Received:2023-07-24 Published:2024-02-25
  • Corresponding author: Zhen Gan
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陈涛, 石红建, 周良, 甘振. 介入治疗胃胆胰术后迟发性出血的临床疗效与安全性[J]. 中华介入放射学电子杂志, 2024, 12(01): 39-44.

Tao Chen, Hongjian Shi, Liang Zhou, Zhen Gan. Interventional treatment for delayed postoperative hemorrhage after gastric and pancreatic-biliary surgery[J]. Chinese Journal of Interventional Radiology(Electronic Edition), 2024, 12(01): 39-44.

目的

探讨介入治疗胃胆胰术后迟发性出血临床疗效与安全性。

方法

回顾性分析2016年1月至2021年6月南京医科大学第二附属医院胃胆胰术后迟发性出血24例患者的临床资料。主要观察指标为技术成功率和临床有效率，次要观察指标为介入相关并发症。

结果

所有病例动脉造影均明确出血责任动脉，诊断阳性率100%。2例栓塞治疗失败行外科手术治疗，总体技术成功率91.7%。术后15例治愈出院；4例再次出血行二次介入治疗，3例住院期间死亡，总体临床有效率62.5%。介入相关并发症包括肝脏缺血5例，肝脏梗塞2例，脾脏梗塞2例，总体并发症发生率37.5%。根据出血责任动脉不同分为肝外肝动脉组（n = 11）和其他动脉组（n = 13），两组技术成功率和临床有效率差异无统计学意义（P > 0.05），但是两组并发症发生率差异有统计学意义（P = 0.033）。

结论

介入治疗胃胆胰术后迟发性出血诊断阳性率高，治疗效果确切，严重并发症少见，可作为首选方法。

关键词: 迟发性出血, 介入治疗, 胃胆胰手术
Objective

To evaluate the clinical efficacy and safety of interventional treatment for delayed hemorrhage after gastric and pancreatic-biliary surgery.

Methods

The clinical data of 24 patients with delayed hemorrhage after gastric and pancreatic-biliary surgery treated by the authors' hospital from January 2016 to June 2021 were retrospectively analyzed. The primary endpoints were the technical success and the clinical efficacy rate, and the secondary endpoints were interventional treatment-related complications.

Results

The responsible arteries were identified by angiography in all cases, and the diagnostic positive rate was 100%. Embolization failed in two cases which underwent the second surgery, and the overall technical success rate was 91.7%.15 cases were cured and discharged after treatment. The second interventional treatment was performed in 4 cases with recurrent bleeding, and 3 patients died during hospitalization. The overall clinical efficacy rate was 62.5%. The interventional treatment-related complications included liver ischemia in 5 cases, liver infarction in 2 cases and spleen infarction in 2 cases. The overall complication rate was 37.5%. The cases were divided into the extrahepatic hepatic artery group (n = 11) and the other artery group (n = 13) according to different responsible arteries. There was no significant difference in the technical success rate and the clinical efficacy rate between the two groups (P > 0.05), but the difference of the interventional treatment-related complication rate between the two groups was significant (P = 0.033).

Conclusion

Interventional treatment could be the first choice for delayed hemorrhage after gastric and pancreatic-biliary surgery due to its high diagnostic positive rate, definite therapeutic effect and rare serious complications.

Key words: Delayed hemorrhage, Interventional treatment, Gastric and pancreatic-biliary surgery
图1 肝外肝动脉组与其他动脉组出血间隔时间、介入治疗前血红蛋白变化及休克指数1A：肝外肝动脉组与其他组出血时间箱线图；1B：肝外肝动脉组与其他组血红蛋白变化箱线图；1C：肝外肝动脉组与其他组休克指数箱线图。
表1 两组患者一般资料比较
项目 总体(24例) 肝外肝动脉组(11例) 其他动脉组(13例) P值
性别[例(%)]       0.357
男性 18 (75.0) 7 (63.6) 11 (84.6)  
女性 6 (25.0) 4 (36.4) 2 (15.4)  
年龄(岁，±s) 63.6±13.2 64.2±13.8 63.1±13.3 0.844
原发疾病[例(%)]       0.999
胰腺癌 9 (37.5) 5 (45.5) 4 (30.8)  
胃癌 5 (20.8) 2 (18.2) 3 (23.1)  
胆管癌 3 (12.5) 2 (18.2) 1 (7.7)  
胰腺囊腺瘤 2 (8.3) 0 (0.0) 2 (15.4)  
重症胰腺炎 2 (8.3) 0 (0.0) 2 (15.4)  
壶腹癌 2 (8.3) 1 (9.1) 1 (7.7)  
胰腺神经源性肿瘤 1 (4.2) 1 (9.1) 0 (0.0)  
术式[例(%)]       0.041
胰十二指肠切除 14 (58.3) 9 (81.8) 5 (38.5)  
胃切除 5 (20.8) 2 (18.2) 3 (23.1)  
重症胰腺炎清创引流 2 (8.3) 0 (0.0) 2 (15.4)  
胰腺消融及胆肠吻合 2 (8.3) 0 (0.0) 2 (15.4)  
胰体尾切除 1 (4.2) 0 (0.0) 1 (7.7)  
临床表现[例(%)]        
窦道或引流管出血 15 (62.5) 6 (54.5) 9 (69.2) 0.999
血便 5 (20.8) 2 (18.2) 3 (23.1)  
腹腔出血 3 (12.5) 2 (18.2) 1 (7.7)  
窦道出血及血便 1 (4.2) 1 (9.1) 0 (0.0)  
消化道瘘[例(%)]       0.240
肠瘘 4 (16.7) 2 (18.2) 2 (15.4)  
胰瘘 8 (33.3) 4 (36.4) 4 (30.8)  
胆瘘 2 (8.3) 2 (18.2) 0 (0.0)  
没有或不确定 10 (41.7) 3 (27.3) 7 (53.8)  
出血间隔时间(d，±s) 17.4±14.8 21.4±9.2 14.1±17.9 0.237
血红蛋白变化( g/L，±s) 34.8±9.7 40.2±6.3 30.2±10.0 0.009
休克指数(±s) 1.46±0.38 1.64±0.28 1.31±0.40 0.034
图2 胰十二指肠切除术后血便1例2A：肝总动脉造影见肝总动脉破裂出血；2B：引入加硬导丝及7F长鞘，造影见输入袢肠管显影（白色箭头）；2C：Viabahn覆膜支架植入后造影，覆膜支架隔绝出血动脉，肝总动脉及远段肝动脉分支通畅。
表2 两组患者手术结果比较[例（%）]
项目 总体(24例) 肝外肝动脉组(11例) 其他动脉组(13例) P值
责任血管       <0.001
胃十二指肠动脉残端 5 (20.8) 5 (45.5) 0 (0.0)  
肝总动脉 4 (16.7) 4 (36.4) 0 (0.0)  
脾动脉 4 (16.7) 0 (0.0) 4 (30.8)  
空肠动脉 3 (12.5) 0 (0.0) 3 (23.1)  
肝固有动脉 2 (8.3) 2 (18.2) 0 (0.0)  
胃十二指肠动脉 2 (8.3) 0 (0.0) 2 (15.4)  
胰十二指肠动脉 2 (8.3) 0 (0.0) 2 (15.4)  
胃左动脉 1 (4.2) 0 (0.0) 1 (7.7)  
膈下动脉 1 (4.2) 0 (0.0) 1 (7.7)  
DSA表现       0.999
血管破裂 15 (62.5) 7 (63.6) 8 (61.5)  
假性动脉瘤形成 9 (37.5) 4 (36.4) 5 (38.5)  
栓塞材料       0.065
微弹簧圈 12 (50.0) 7 (63.6) 5 (38.5)  
医用胶 5 (20.8) 0 (0) 5(38.5)  
微弹簧圈和医用胶 3 (12.5) 1 (9.1) 2 (15.4)  
覆膜支架 2 (8.3) 2 (18.2) 0 (0.0)  
未栓塞 2 (8.3) 1 (9.1) 1 (7.7)  
图3 肝外肝动脉组介入治疗术后转氨酶变化，虚线示肝功能衰竭死亡病例3A：肝外肝动脉组介入治疗术后谷草转氨酶（AST）变化；3B：肝外肝动脉组介入治疗术后谷丙转氨酶（ALT）变化。
表3 两组患者评价指标比较[例（%）]
项目 总体(24例) 肝外肝动脉组(11例) 其他动脉组(13例) P值
结局       0.835
治愈 15 (62.5) 7 (63.6) 8 (61.5)  
复发 4 (16.7) 1 (9.1) 3 (23.1)  
二次手术 2 (8.3) 1 (9.1) 1 (7.7)  
死亡 3 (12.5) 2 (18.2) 1 (7.7)  
诊断阳性率 24 (100.0) 11 (100.0) 13 (100.0) 0.999
技术成功率 22 (91.7) 10 (90.9) 12 (92.3) 0.999
临床有效率 15 (62.5) 7 (63.6) 8 (61.5) 0.999
并发症 9 (37.5) 7 (63.6) 2 (15.4) 0.033
肝脏缺血 5 (20.8) 5 (45.5) 0 (0.0)  
肝脏梗塞 2 (8.3) 2 (18.2) 0 (0.0)  
脾脏梗塞 2 (8.3) 0 (0.0) 2 (15.4)  
并发症CIRSE分级        
一级或二级 7 (29.2) 5 (45.5) 2 (15.4)  
三级及以上 2 (8.3) 2 (18.2) 0 (0.0)  
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