Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA.
J Am Coll Surg. 2012 Nov;215(5):616-21. doi: 10.1016/j.jamcollsurg.2012.07.010. Epub 2012 Aug 24.
Postpancreatectomy hemorrhage (PPH) is a life-threatening complication of pancreatic resection. Most published series span decades and do not reflect contemporary practice. This study analyzes the rate, management, and outcomes of PPH during a recent 5-year period.
Patients in whom PPH developed between 2006 and 2011 were identified from a prospective database. Postpancreatectomy hemorrhage was defined as evidence of bleeding associated with a drop in hemoglobin (≥ 3 g/dL) and/or clinical signs of hemodynamic compromise, and categorized as early or late (<24 hours or >24 hours from operation). Demographics and operative and perioperative outcomes were analyzed using standard descriptive statistics.
Overall incidence of PPH was 3% (33 of 1,122 pancreatectomies) and was similar for pancreaticoduodenectomy (25 of 739 [3%]), distal (6 of 350 [2%]), and central pancreatectomy (2 of 31 [6%]) (p = 0.26). Early hemorrhage was seen in 21% (7 of 33) and was always extraluminal; these patients underwent reoperation and recovered fully. Late hemorrhage (26 of 33 [79%]) was predominantly intraluminal (18 of 26 [69%]), occurring at a median of 12 days postoperatively (4 to 23 days), and was treated endoscopically (13 of 26 [50%]), angiographically (10 of 26 [38%]), or surgically (3 of 26 [10%]). Postpancreatectomy hemorrhage was associated with longer hospitalization (10 [range 8 to 17] days vs 7 [range 6 to 9] days; p < 0.01); mortality, however, was not increased (1 of 33 [3%] vs 17 of 1,089 [2%]; p = 0.95). Hemorrhage began after discharge in 39% of patients (13 of 33), with the only death occurring in a patient from this group.
Postpancreatectomy hemorrhage can be managed successfully with low mortality (3%). Early hemorrhage requires urgent reoperation, and management of delayed hemorrhage should be guided by location (intra- vs extraluminal). Greater pressure to reduce length of hospital stay appears to have increased the likelihood of PPH occurring after discharge; patients and physicians should be aware of this possibility.
胰切除术后出血（PPH）是一种危及生命的并发症。大多数已发表的系列研究跨越了数十年，并未反映当代的实践情况。本研究分析了最近 5 年期间 PPH 的发生率、治疗方法和结果。
从前瞻性数据库中确定了 2006 年至 2011 年间发生 PPH 的患者。胰切除术后出血的定义为与血红蛋白下降（≥3g/dL）相关的出血证据和/或血流动力学不稳定的临床体征，并分为早期或晚期（<24 小时或>24 小时手术）。使用标准描述性统计方法分析人口统计学和手术及围手术期结果。
PPH 的总发生率为 3%（1122 例胰腺切除术中有 33 例），胰十二指肠切除术（25/739，3%）、远端胰腺切除术（6/350，2%）和中央胰腺切除术（2/31，6%）的发生率相似（p=0.26）。早期出血占 21%（7/33），且均为外出血；这些患者接受了再次手术并完全康复。晚期出血（26/33，79%）主要为内出血（26/26，69%），中位时间为术后 12 天（4 至 23 天），经内镜（13/26，50%）、血管造影（10/26，38%）或手术治疗（3/26，10%）。胰切除术后出血与住院时间延长相关（10[范围 8 至 17]天 vs 7[范围 6 至 9]天；p<0.01）；但死亡率没有增加（33 例中有 1 例[3%] vs 1089 例中有 17 例[2%]；p=0.95）。39%的患者（13/33）在出院后开始出现出血，唯一的死亡发生在该组患者中。
胰切除术后出血可以成功治疗，死亡率低（3%）。早期出血需要紧急再次手术，延迟性出血的治疗应根据部位（内出血与外出血）而定。降低住院时间的压力似乎增加了 PPH 出院后发生的可能性；患者和医生应意识到这种可能性。
