Asari Sadaki, Matsumoto Ippei, Toyama Hirochika, Yamaguchi Masato, Okada Takuya, Shinzeki Makoto, Goto Tadahiro, Ajiki Tetsuo, Fukumoto Takumi, Ku Yonson
Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Japan.
Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Japan.
Pancreatology. 2016 May-Jun;16(3):454-63. doi: 10.1016/j.pan.2016.02.003. Epub 2016 Feb 17.
Postpancreatectomy hemorrhage (PPH) is a life-threatening complication of pancreatic surgery. The shift from surgical to radiological intervention was recently reported in retrospective cohort studies, but it has remained controversial as to which emergent intervention provides optimal management.
All 553 patients who underwent standard pancreatic resection at Kobe University Hospital between January 2003 and December 2013 were included. Patient data and complication data were identified from a prospective database.
The overall incidence of PPH was 6% (35 of 553 patients). Ten patients underwent endoscopic intervention or observation monitoring, or suffered hemorrhagic sudden death. Among the remaining 25 PPH patients, primary surgical intervention was successful in the 6 hemodynamically unstable PPH patients. Primary radiological intervention could successfully stop the bleeding in 15 of the 17 patients with late-PPH. Nine patients who had bleeding from the hepatic artery after pancreaticoduodenectomy were rescued by endovascular embolization of the artery-trunk. The in-hospital mortality of PPH was 20% (7 of 35). Four of the 5 PPH patients who died following any intervention eventually died due to the other complications associated with prolonged pancreatic fistula.
The leading treatment has been radiological intervention. Endovascular embolization of the hepatic artery-trunk can be securely performed only if blood flow to the liver by an alternate route is confirmed. To reduce mortality of PPH patients, it is necessary to prevent other complications associated with pancreatic fistula following hemostasis. Proactive surgical intervention such as abscess drainage or remnant pancreatectomy is a key consideration.
胰十二指肠切除术后出血（PPH）是胰腺手术中一种危及生命的并发症。近期回顾性队列研究报道了从手术干预向放射介入的转变，但哪种紧急干预能提供最佳治疗仍存在争议。
纳入2003年1月至2013年12月在神户大学医院接受标准胰腺切除术的所有553例患者。从前瞻性数据库中识别患者数据和并发症数据。
PPH的总体发生率为6%（553例患者中的35例）。10例患者接受了内镜干预、观察监测或发生出血性猝死。在其余25例PPH患者中，6例血流动力学不稳定的PPH患者接受一期手术干预成功。17例迟发性PPH患者中有15例通过一期放射介入成功止血。9例胰十二指肠切除术后肝动脉出血的患者通过肝动脉主干血管内栓塞获救。PPH患者的院内死亡率为20%（35例中的7例）。5例接受任何干预后死亡的PPH患者中有4例最终死于与长期胰瘘相关的其他并发症。
主要治疗方法一直是放射介入。仅当确认有替代途径向肝脏供血时，才能安全地进行肝动脉主干血管内栓塞。为降低PPH患者的死亡率，止血后有必要预防与胰瘘相关的其他并发症。积极的手术干预，如脓肿引流或残留胰腺切除术是关键考虑因素。
