Carr J A, Cho J S, Shepard A D, Nypaver T J, Reddy D J
Division of Vascular Surgery, Henry Ford Hospital, Detroit, MI 48202, USA.
J Vasc Surg. 2000 Oct;32(4):722-30. doi: 10.1067/mva.2000.110055.
Erosion of pancreatic pseudocysts into adjacent vessels is a rare but highly lethal cause of intra-abdominal hemorrhage. Percutaneous angiographic embolization (PAE) of the bleeding artery has recently been advocated as the preferred therapy. This study was undertaken to survey the outcome after treatment of this complication and to make recommendations for its management.
An 11-year retrospective analysis was performed of all patients treated at a large tertiary care referral center for visceral artery pseudoaneurysms associated with pancreatic pseudocysts.
From 1988 to 1998, 256 patients were admitted for complications of pancreatic pseudocysts. Sixteen patients (11 men and 5 women) were identified in whom a pseudocyst had eroded into a major blood vessel with hemorrhage or development of a false aneurysm. The mean age was 45 years (range, 23-67 years). Active bleeding was present in 13 patients, whereas three had evidence of recent hemorrhage. Ten of 16 patients initially underwent operative therapy, four elective and six emergency, whereas six stable patients were initially treated with PAE. Technical failures of the initial treatment or secondary complications required both therapeutic modalities in six patients, which resulted in 13 total surgical interventions and 10 PAEs. The surgical morbidity rate was 62% (8 of 13), whereas that of PAE was 50% (5 of 10). Three deaths occurred after emergency operations, two of which failed to stop the bleeding, accounting for all of the deaths in the series (3 [19%] of 16). A trend was noted toward increased death with necrotizing pancreatitis (P =.07) and emergency surgery (P =.06). Ranson's criteria were not found to be predictive of death in this series. Surgical drainage procedures were required in seven (44%) of 16 patients for infections (n = 3) or mass effect of the pseudoaneurysm (n = 3). The mean size of pseudoaneurysms that required operative intervention for secondary complications was 13.9 cm, compared with 7.7 cm for all others in the series (P =.046). Long-term follow-up was available in all 13 survivors at a mean of 44 months (range, 1-108 months).
The management of pancreatic pseudocyst-associated pseudoaneurysms remains a challenging problem with high morbidity and death rates. Operation and PAE play complementary management roles. PAE is recommended as the initial therapy for hemodynamically stable patients. Surgery should be reserved for actively bleeding, hemodynamically unstable patients; for failed embolization; and for other secondary complications such as infection or extrinsic compression.
胰腺假性囊肿侵蚀相邻血管是腹腔内出血的一种罕见但极具致死性的原因。近来有人主张对出血动脉进行经皮血管造影栓塞术（PAE）作为首选治疗方法。本研究旨在调查该并发症治疗后的结果并对其处理提出建议。
对一家大型三级医疗转诊中心收治的所有与胰腺假性囊肿相关的内脏动脉假性动脉瘤患者进行了11年的回顾性分析。
1988年至1998年，256例患者因胰腺假性囊肿并发症入院。16例患者（11例男性和5例女性）被确定为假性囊肿侵蚀入主要血管并伴有出血或假性动脉瘤形成。平均年龄为4岁（范围23 - 67岁）。13例患者有活动性出血，3例有近期出血证据。16例患者中有10例最初接受了手术治疗，4例为择期手术，6例为急诊手术，而6例病情稳定的患者最初接受了PAE治疗。6例患者因初始治疗技术失败或继发并发症需要两种治疗方式，共进行了13次手术干预和10次PAE治疗。手术的发病率为62%（13例中的8例），而PAE的发病率为50%（10例中的5例）。3例患者在急诊手术后死亡，其中2例未能止血，占该系列所有死亡病例（16例中的3例[19%]）。观察到坏死性胰腺炎（P = 0.07）和急诊手术（P = 0.06）导致死亡的趋势增加。在本系列中未发现兰森标准可预测死亡。16例患者中有7例（44%）因感染（n = 3）或假性动脉瘤的占位效应（n = 3）需要进行手术引流。因继发并发症需要手术干预的假性动脉瘤平均大小为13.9 cm，而该系列中其他所有假性动脉瘤的平均大小为7.7 cm（P = 0.046）。13例幸存者均获得了平均44个月（范围1 - 108个月）的长期随访。
胰腺假性囊肿相关假性动脉瘤的处理仍然是一个具有高发病率和死亡率的挑战性问题。手术和PAE发挥着互补的管理作用。对于血流动力学稳定的患者，建议将PAE作为初始治疗方法。手术应保留给有活动性出血且血流动力学不稳定的患者、栓塞失败的患者以及其他继发并发症如感染或外部压迫的患者。
