Miura Fumihiko, Asano Takehide, Amano Hodaka, Yoshida Masahiro, Toyota Naoyuki, Wada Keita, Kato Kenichiro, Yamazaki Eriko, Kadowaki Susumu, Shibuya Makoto, Maeno Sawako, Furui Shigeru, Takeshita Koji, Kotake Yutaka, Takada Tadahiro
Department of Surgery, Teikyo University School of Medicine, Itabashi-ku, Tokyo, Japan.
J Hepatobiliary Pancreat Surg. 2009;16(1):56-63. doi: 10.1007/s00534-008-0012-3. Epub 2008 Dec 26.
BACKGROUND/PURPOSE: Intra-abdominal arterial hemorrhage is still one of the most serious complications after pancreato-biliary surgery. We retrospectively analyzed our experiences with 15 patients in order to establish a therapeutic strategy for postoperative arterial hemorrhage following pancreato-biliary surgery.
Between August 1981 and November 2007, 15 patients developed massive intra-abdominal arterial bleeding after pancreato-biliary surgery. The initial surgery of these 15 patients were pylorus-preserving pancreatoduodenectomy (PPPD) (7 patients), hemihepatectomy and caudate lobectomy with extrahepatic bile duct resection or PPPD (4 patients), Whipple's pancreatoduodenectomy (PD) (3 patients), and total pancreatectomy (1 patient). Twelve patients were managed by transcatheter arterial embolization and three patients underwent re-laparotomy.
Patients were divided into two groups according to the site of bleeding: SMA group, superior mesenteric artery (4 patients); HA group, stump of gastroduodenal artery, right hepatic artery, common hepatic artery, or proper hepatic artery (11 patients). In the SMA group, re-laparotomy and coil embolization for pseudoaneurysm were performed in three and one patients, respectively, but none of the patients survived. In the HA group, all 11 patients were managed by transcatheter arterial embolization. None of four patients who had major hepatectomy with extrahepatic bile duct resection survived. Six of seven patients (85.7%) who had pancreatectomy survived, although hepatic infarction occurred in four.
Management of postoperative arterial hemorrhage after pancreato-biliary surgery should be done according to the site of bleeding and the initial operative procedure. Careful consideration is required for indication of interventional radiology for bleeding from SMA after pancreatectomy and hepatic artery after major hepatectomy with bilioenteric anastomosis.
背景/目的：腹腔内动脉出血仍是胰胆手术后最严重的并发症之一。我们回顾性分析了15例患者的经验，以建立胰胆手术后动脉出血的治疗策略。
1981年8月至2007年11月期间，15例患者在胰胆手术后发生大量腹腔内动脉出血。这15例患者的初次手术包括保留幽门的胰十二指肠切除术（PPPD）（7例）、半肝切除及尾状叶切除联合肝外胆管切除或PPPD（4例）、惠普尔胰十二指肠切除术（PD）（3例）和全胰切除术（1例）。12例患者接受了经导管动脉栓塞治疗，3例患者接受了再次剖腹手术。
根据出血部位将患者分为两组：肠系膜上动脉（SMA）组，4例；肝动脉（HA）组，胃十二指肠动脉残端、右肝动脉、肝总动脉或肝固有动脉，11例。在SMA组中，分别有3例和1例患者接受了再次剖腹手术和假性动脉瘤的弹簧圈栓塞，但无一例患者存活。在HA组中，所有11例患者均接受了经导管动脉栓塞治疗。接受肝外胆管切除的大肝切除患者中，4例无一存活。7例接受胰切除术的患者中有6例（85.7%）存活，尽管4例发生了肝梗死。
胰胆手术后动脉出血的处理应根据出血部位和初次手术方式进行。对于胰切除术后SMA出血和大肝切除联合胆肠吻合术后肝动脉出血的介入放射学指征，需要仔细考虑。
