Merdrignac Aude, Bergeat Damien, Levi Sandri Giovanni Battista, Agus Marina, Boudjema Karim, Sulpice Laurent, Meunier Bernard
Department of Hepato-Biliary and Digestive Surgery, CHU de Rennes, Rennes, France.
Gland Surg. 2016 Aug;5(4):427-30. doi: 10.21037/gs.2016.02.04.
Post-pancreatectomy hemorrhage (PPH) is a major complication occurring in 6-8% of patients after pancreaticoduodenectomy (PD). Arterial bleeding is the most frequent cause. Mortality rate could reach 30% after grade C PPH according to ISGPS classification. Complete interruption of hepatic arterial flow has to be a salvage procedure because of the high risk of intrahepatic abscess following the procedure. We report a technique to perform an artery reinforcement after PPH caused by pancreatitis. A PD according to Whipple's procedure with child's reconstruction was performed in a 68-year-old man. At postoperative day 12, the patient presented a sudden violent abdominal pain with arterial hypotension and tachycardia. Computed tomography (CT) with intravenous contrast injection was performed. Arterial and venous phases showed a contrast extravasation on the hepatic artery. Origin of PPH was found as an erosion of hepatic artery caused by pancreatic leak. A peritoneal patch was placed around hepatic artery to reinforce damaged arterial wall. The peritoneal patch was harvested from right hypochondrium with a thin preperitoneal fat layer. The patch was sutured around hepatic artery with musculoaponeurotic face placed on the arterial wall. A CT was performed and hepatic artery was permeable with normal caliber in the portion of peritoneal patch reinforcement. The technique described in the present case consists in reinforcing directly arterial wall after occurrence of PPH. The use of a peritoneal patch during pancreatic surgery has first been described to replace a portion of portal vein after venous resection with the peritoneal layer placed on the intraluminal side of the vein. The present case describes a salvage technique to reinforce damaged artery after PPH in context of pancreatic leak. This simple technique could be useful to avoid complex arterial reconstruction and recurrent bleeding in septic context.
胰十二指肠切除术后出血（PPH）是胰十二指肠切除术（PD）后6%-8%患者发生的一种主要并发症。动脉出血是最常见的原因。根据国际胰腺外科研究小组（ISGPS）分类，C级PPH后的死亡率可达30%。由于该手术后肝内脓肿风险高，肝动脉血流的完全中断必须作为一种挽救性手术。我们报告一种在胰腺炎导致PPH后进行动脉强化的技术。一名68岁男性接受了按照Whipple手术并采用Child重建法的PD手术。术后第12天，患者突然出现剧烈腹痛，伴有动脉低血压和心动过速。进行了静脉注射造影剂的计算机断层扫描（CT）。动脉期和静脉期显示肝动脉有造影剂外渗。发现PPH的原因是胰漏导致肝动脉侵蚀。在肝动脉周围放置一块腹膜补片以强化受损的动脉壁。腹膜补片取自右季肋区，带有一层薄的腹膜前脂肪层。将补片围绕肝动脉缝合，使肌筋膜面置于动脉壁上。进行了CT检查，在腹膜补片强化部分，肝动脉通畅且管径正常。本病例中描述的技术在于在PPH发生后直接强化动脉壁。在胰腺手术中使用腹膜补片最早是为了在静脉切除后用置于静脉腔内的腹膜层替代部分门静脉。本病例描述了一种在胰漏情况下PPH后强化受损动脉的挽救技术。这种简单技术可能有助于避免复杂的动脉重建和感染情况下的复发性出血。
