胰十二指肠切除术后胰瘘合并出血二次手术2例并国内文献复习

doi:10.3969/j.issn.1009-976X.2021.01.012

摘要/Abstract

摘要： 目的关于胰十二指肠切除术后胰瘘合并出血的二次手术方式缺乏相应的指南及专家共识,本文旨在复习胰十二指肠切除术后胰瘘合并出血的二次手术方式并探讨胰十二指肠切除术后胰瘘合并出血治疗方案。方法回顾分析2例胰十二指肠切除术后C级胰瘘合并出血的诊疗及手术过程,对胰十二指肠切除术后胰瘘合并出血的二次手术方式进行文献复习。结果 2例胰十二指肠切除术后C级胰瘘合并出血的患者,均在保守治疗无效的情况下进行了二次手术。患者1在探查胰肠吻合口时,发现门静脉出血,确切止血后重新行原位的胰肠吻合术,最终痊愈出院;患者2由于胰瘘导致了迟发性的出血及腹腔感染,在二次手术时并未发现明确的责任血管,手术中对出血风险较高的血管进行了结扎,并对胰肠吻合口进行了加针修补,最终患者因全身多器官功能衰竭死亡。结论 PD术后胰瘘合并出血的治疗需要介入科、重症医学科、普外科的多学科参与,外科手术仍然是PD术后胰瘘合并出血的关键一环。

关键词: 胰十二指肠切除术, 术后并发症, 胰瘘, 出血, 二次手术

Abstract: Objective This article aim was to review the relaparotomy methods and to discuss the treatment scheme of severe pancreatic fistula with hemorrhage. Methods The diagnosis, treatment and relaparotomy process of two cases of grade C pancreatic fistula complicated withhemorrhage after pancreaticoduodenectomy were retrospectively analyzed, and the reoperation methods of pancreatic fistula complicated with hemorrhage after pancreaticoduodenectomy were reviewed. Results Two patients with grade C pancreatic fistula complicated with hemorrhage underwent the rescue resection. The first patient was found portal vein bleeding when explored the pancreaticointestinal anastomosis. After stopping bleeding, we underwent in-situ pancreaticojejunostomy. The first patient finally recovered. The second patient suffered from delayed hemorrhage and abdominal infection due to pancreatic fistula. No clear responsible blood vessels were found during the reoperation process. The blood vessels with high risk of bleeding were ligated during the relaparotomy, and the Pancreaticointestinal anastomosis was repaired. Eventually, the patient died of multiple systematic organ failure（MSOF）. Conclusion The treatment of pancreatic fistula complicated with. Hemorrhage after PD often requires multidisciplinary participation of interventional department, ICU and surgical department. Surgery still playthe important role in pancreatic fistula complicated with hemorrhage after PD.

Key words: pancreatoduodenectomy, postoperative complications, pancreatic fistula, hemorrhage, reoperation

中图分类号:

R656.6

刘钧豪, 罗宇荣, 李海量, 李晓锋, 高鹏, 曾宪成. 胰十二指肠切除术后胰瘘合并出血二次手术2例并国内文献复习[J]. 岭南现代临床外科, 2021, 21(01): 68-73.

LIU Jun-hao, LUO Yu-rong, LI Hai-liang, LI Xiao-feng, GAO Peng, ZENG Xian-cheng. Two cases report of reoperation for pancreatic fistula complicated with hemorrhage after pancreatoduodenectomy and literature review[J]. Lingnan Modern Clinics In Surgery, 2021, 21(01): 68-73.

参考文献

[1] 薛鸿,陈江明,谢胜学,等. 胰十二指肠切除术后发生胰瘘的危险因素分析[J]. 中华胰腺病杂志, 2020, 20(4): 259-264.
[2] Smits FJ, Verweij ME, Daamen LA, et al.Impact of Complications After Pancreatoduodenectomy on Mortality, Organ Failure, Hospital Stay, and Readmission: Analysis of a Nationwide Audit[J]. Ann Surg, 2020. doi: 10.1097/SLA. 0000000000003835.[Epub ahead of print]
[3] 刘国华, 谭小宇, 戴东, 等. 改良Blumgart胰肠吻合在胰十二指肠切除术中的应用[J]. 中国普通外科杂志, 2020, 29(3):276-283.
[4] Cheng Y, Briarava M, Lai M, et al. Pancreaticojejunostomy versus pancreaticogastrostomy reconstruction for the prevention of postoperative pancreatic fistula following pancreaticoduodenectomy [J]. Cochrane Database Syst Rev, 2017, 2017, 9(9):CD012257.
[5] Schafer M, Heinrich S, Pfammatter T, et al.Management of delayed major visceral arterial bleeding after pancreatic surgery[J]. HPB (Oxford), 2011, 13(2): 132-138.
[6] Ecker BL, Mcmillan MT, Asbun HJ, et al.Characterization and Optimal Management of High-risk Pancreatic Anastomoses During Pancreatoduodenectomy[J]. Ann Surg, 2018, 267(4): 608-616.
[7] Shrikhande SV, Sivasanker M, Vollmer CM, et al.Pancreatic anastomosis after pancreatoduodenectomy: A position statement by the International Study Group of Pancreatic Surgery (ISGPS)[J]. Surgery, 2017, 161(5): 1221-1234.
[8] Wroński M, Cebulski W, Witkowski B, et al.Surgical management of the grade C pancreatic fistula after pancreatoduodenectomy[J]. HPB (Oxford), 2019, 21(9): 1166-1174.
[9] 卢昕, 金浩生, 侯宝华, 等. 胰十二指肠切除术围术期规范化开展加速康复外科的几点争议[J]. 中国普通外科杂志,2017, 26(9):1207-1211.
[10] Ansari D, Tingstedt B, Lindell G, et al.Hemorrhage after Major Pancreatic Resection: Incidence, Risk Factors, Management, and Outcome[J]. Scand J Surg, 2017, 106(1): 47-53.
[11] Okuno A, Miyazaki M, Ito H, et al.Nonsurgical management of ruptured pseudoaneurysm in patients with hepatobiliary pancreatic diseases[J]. Am J Gastroenterol, 2001, 96(4): 1067-1071.
[12] Reber PU, Baer HU, Patel AG, et al.Life-threatening upper gastrointestinal tract bleeding caused by ruptured extrahepatic pseudoaneurysm after pancreatoduodenectomy[J]. Surgery, 1998, 124(1): 114-115.
[13] Jilesen AP, Tol JA, Busch OR, et al.Emergency management in patients with late hemorrhage after pancreatoduodenectomy for a periampullary tumor[J]. World J Surg, 2014, 38(9): 2438-2447.
[14] 刘军桂,刘全达,金奎,等. 胆胰分离术在胰十二指肠切除术后C级胰瘘治疗中的应用[J]. 腹部外科, 2019, 32(5): 346-349.
[15] 梁兴, 胡先贵, 金钢, 等. 胰肠吻合口瘘合并出血28例治疗体会[J]. 中华肝胆外科杂志, 2015, 21(4): 276-277.
[16] 段小辉,刘小梯,吴浩然,等. 腹腔镜胰十二指肠切除术后再手术十例分析[J]. 中华肝胆外科杂志, 2019, 25(2): 102-105.
[17] 冯健, 赵向前,张航宇,等. 胰十二指肠切除术后门静脉系统严重出血诊断与治疗[J].中华肝脏外科手术学电子杂志,2018,7(6):482-485.
[18] 吴建武,秦安成,乔志明,等. 胰十二指肠切除术后胰瘘合并迟发性腹腔出血的诊治体会[J]. 岭南现代临床外科,2016, 16(4): 380-382.
[19] 张健,韩广森. 胰十二指肠切除术后胰瘘致胰肠吻合口大出血再手术治疗一例[J]. 中国综合临床, 2012, 28(4): 443.
[20] Bassi C, Marchegiani G, Dervenis C, et al.The 2016 update of the International Study Group (ISGPS) definition and grading of postoperative pancreatic fistula: 11 Years After[J]. Surgery, 2017, 161(3): 584-591.
[21] Wente MN, Veit JA, Bassi C, et al.Postpancreatectomy hemorrhage (PPH): an International Study Group of Pancreatic Surgery (ISGPS) definition[J]. Surgery, 2007, 142(1): 20-25.
[22] 沈柏用, 陈亚进, 彭兵,等. 胰十二指肠切除术后出血的预防及处理[J]. 中华消化外科杂志, 2018, 17(7): 682-686.
[23] Sanjay P, Kellner M, Tait IS.The role of interventional radiology in the management of surgical complications after pancreatoduodenectomy[J]. HPB (Oxford), 2012, 14(12): 812-817.
[24] Ribero D, Amisano M, Zimmitti G, et al.External tube pancreatostomy reduces the risk of mortality associated with completion pancreatectomy for symptomatic fistulas complicating pancreaticoduodenectomy[J]. J Gastrointest Surg, 2013, 17(2): 332-338.
[25] Denost Q, Pontallier A, Rault A, et al.Wirsungostomy as a salvage procedure after pancreaticoduodenectomy[J]. HPB (Oxford), 2012, 14(2): 82-86.
[26] De Castro SM, Busch OR, Van Gulik TM, et al.Incidence and management of pancreatic leakage after pancreatoduodenectomy[J]. Br J Surg, 2005, 92(9): 1117-1123.
[27] Bachellier P, Oussoultzoglou E, Rosso E,et al. Pancreatogastrostomy as a salvage procedure to treat severe postoperative pancreatic fistula after pancreatoduodenectomy [J]. Arch Surg, 2008, 143(10): 966-970; discussion 71.
[28] Bouras AF, Marin H, Bouzid C, et al.Pancreas-preserving management in reinterventions for severe pancreatic fistula after pancreatoduodenectomy: a systematic review[J]. Langenbecks Arch Surg, 2016, 401(2): 141-149.
[29] Gachabayov M, Gogna S, Latifi R, et al.Passive drainage to gravity and closed-suction drainage following pancreatoduodenectomy lead to similar grade B and C postoperative pancreatic fistula rates. A meta-analysis[J]. Int J Surg, 2019, 67: 24-31.
[30] 戴显伟,徐进. 胰十二指肠切除术后吻合口裂开的预防与治疗策略[J]. 中华消化外科杂志, 2013, 12(2): 109-112.