DSA在胰十二指肠切除术后迟发性出血诊断和治疗中的临床价值

doi:10.16139/j.1007-9610.2025.02.06

摘要/Abstract

摘要：

目的：评估数字减影血管造影（DSA）在胰十二指肠切除术（PD）后迟发性出血中的临床疗效及应用价值。方法：对2019年1月至2024年12月期间在复旦大学附属中山医院接受DSA治疗的38例PD术后迟发性出血病人的临床资料进行回顾性分析，重点评估介入治疗的技术成功率及临床效果。结果：在726例PD手术病人中，38例（5.2%）发生迟发性出血。其中，30例（78.9%）DSA检查显示阳性结果。出血部位分布如下：胃十二指肠动脉18例，肝总动脉1例，空肠动脉第一支2例，肝固有动脉2例，肝右动脉1例，肝中动脉1例，肝左动脉3例，脾动脉起始部1例，胃网膜右动脉1例。介入治疗方式包括微弹簧圈栓塞（17例）、微弹簧圈联合明胶海绵栓塞（4例）、覆膜支架植入（7例）及单纯明胶海绵和微球栓塞（各1例）。28例（93.3%）通过DSA介入治疗成功止血，2例因再发出血需行手术止血。结论：DSA引导下介入栓塞治疗具有创伤小、定位精准、止血效果确切等优势，可作为PD术后迟发性出血的首选治疗策略。

关键词: 胰十二指肠切除术, 胰十二指肠切除术后出血, 数字减影血管造影

Abstract:

Objective To evaluate the clinical efficacy and application value of digital subtraction angiography (DSA) in the management of delayed pancreaticoduodenectomy(PD) hemorrhage(PPH).Methods A retrospective analysis was conducted on the clinical data of 38 patients who underwent DSA for delayed PPH at Zhongshan Hospital, Fudan University, between January 2019 and December 2024. The technical success rate and clinical outcomes of interventional treatment were the primary focus of the evaluation.Results Among 726 patients who underwent PD, 38 (5.2%) experienced delayed bleeding. Of these, 30 (78.9%) showed positive findings on DSA. The distribution of bleeding sites was as follows: gastroduodenal artery (18 cases), common hepatic artery (1 case), the first branch of the jejunal artery (2 cases), proper hepatic artery (2 cases), right hepatic artery (1 case), middle hepatic artery (1 case), left hepatic artery (3 cases), origin of the splenic artery (1 case), and right gastroepiploic artery (1 case). Interventional treatments included microcoil embolization (17 cases), microcoil combined with gelatin sponge embolization (4 cases), covered stent implantation (7 cases), and gelatin sponge embolization alone and microspheres embolization (1 case each). Successful hemostasis was achieved in 28 (93.3%) patients through DSA-guided interventional treatment, while 2 patients required surgical hemostasis due to recurrent bleeding.Conclusions DSA-guided interventional embolization offers advantages such as minimal invasiveness, precise localization, and effective hemostasis, making it the preferred treatment strategy for delayed PPH.

Key words: Pancreaticoduodenectomy(PD), Pancreaticoduodenectomy hemorrhage(PPH), Digital subtraction angiography(DSA)

中图分类号:

王吉文, 王春艳, 沈盛, 刘寒, 张巍, 刘厚宝. DSA在胰十二指肠切除术后迟发性出血诊断和治疗中的临床价值[J]. 外科理论与实践, 2025, 30(2): 125-131.

WANG Jiwen, WANG Chunyan, SHEN Sheng, LIU Han, ZHANG Wei, LIU Houbao. Clinical value of DSA in diagnosis and treatment of delayed pancreaticoduodenectomy hemorrhage[J]. Journal of Surgery Concepts & Practice, 2025, 30(2): 125-131.

图/表 4

表1

表2

迟发性PPH病人表现及DSA结果

No.	Gender	Age	Time of bleeding （postoperative days）	Bleeding manifestation	Target vessel	DSA treatment
1	M	72	7	Gastrointestinal bleeding	The first branch of the jejunal artery	Microcoil embolization of the first jejunal artery branch
2	M	65	8	Intra-abdominal bleeding	Negative	None
3	M	73	25	Gastrointestinal bleeding+ intra-abdominal bleeding	GDA	Microcoil embolization of the proper hepatic artery to the common hepatic artery segment
4	F	68	11	Gastrointestinal bleeding	Negative	None
5	M	57	8	Gastrointestinal bleeding	GDA	Microcoil embolization of the left hepatic artery (with GDA originating from the left hepatic artery)
6	M	65	28	Gastrointestinal bleeding	GDA	Covered stent placement
7	M	68	9	Gastrointestinal bleeding	Left hepatic artery	Gelatin sponge embolization
8	M	73	17	Intra-abdominal bleeding	GDA	Covered stent placement
9	M	57	7	Intra-abdominal bleeding	Negative	None
10	M	70	6	Gastrointestinal bleeding+ intra-abdominal bleeding	Negative	None
11	M	42	9	Intra-abdominal bleeding	Common hepatic artery	Microcoil embolization of the proper hepatic artery to the common hepatic artery segment
12	M	69	10	Intra-abdominal bleeding	GDA	Microcoil embolization of the segment from the right hepatic artery to the common hepatic artery
13	F	61	8	Gastrointestinal bleeding	GDA	Covered stent placement
14	F	59	6	Gastrointestinal bleeding	GDA	Covered stent placement
15	M	61	13	Gastrointestinal bleeding+ intra-abdominal bleeding	GDA	Microcoil embolization of the proper hepatic artery to the common hepatic artery segment，gelatin sponge and microcoil embolization of the middle adrenal artery
16	M	46	12	Intra-abdominal bleeding	Left hepatic artery	Microcoil and gelatin sponge embolization
17	F	71	12	Gastrointestinal bleeding	Left hepatic artery	Microcoil embolization of the proper hepatic artery to the common hepatic artery segment
18	F	60	11	Intra-abdominal bleeding	GDA	Microcoil embolization of the proper hepatic artery to the common hepatic artery segment
19	M	70	8	Intra-abdominal bleeding	Right gastroepiploic artery	Microcoil + gelatin sponge embolization of the left gastroepiploic artery, microcoil embolization of the proper hepatic artery to the common hepatic artery segment
20	M	63	7	Intra-abdominal bleeding	GDA	Microcoil embolization of the GDA stump with gelatin sponge embolization of pancreatic arteries
21	M	71	8	Intra-abdominal bleeding	GDA	Covered stent placement
22	M	63	6	Gastrointestinal bleeding	Middle hepatic artery	Microspheres embolization
23	F	64	11	Intra-abdominal bleeding	GDA	Covered stent placement
24	F	77	11	Intra-abdominal bleeding	GDA	Microcoil embolization of the left hepatic artery (with GDA originating from the left hepatic artery)
25	M	80	22	Intra-abdominal bleeding	GDA	Microcoil embolization of the proper hepatic artery to the common hepatic artery segment
26	M	65	9	Gastrointestinal bleeding+ intra-abdominal bleeding	Proper hepatic artery	Microcoil embolization of the proper hepatic artery to the common hepatic artery segment
27	M	64	35	Intra-abdominal bleeding	The first branch of the jejunal artery	Microcoil embolization of the first jejunal artery branch
28	F	59	9	Intra-abdominal bleeding	GDA	Covered stent placement
29	M	72	19	Intra-abdominal bleeding	Negative	None
30	M	70	8	Gastrointestinal bleeding	GDA	Microcoil embolization of the proper hepatic artery to the common hepatic artery segment
31	M	71	18	Intra-abdominal bleeding	Proper hepatic artery	Microcoil embolization of the proper hepatic artery to the common hepatic artery segment
32	M	67	21	Intra-abdominal bleeding	GDA	Microcoil embolization of the proper hepatic artery to the common hepatic artery segment
33	M	64	6	Intra-abdominal bleeding	GDA	Microcoil embolization of the proper hepatic artery to the common hepatic artery segment
34	F	67	14	Intra-abdominal bleeding	Splenic artery	Microcoil embolization of the splenic artery from its origin to the celiac trunk
35	M	50	15	Intra-abdominal bleeding	Negative	None
36	M	77	7	Intra-abdominal bleeding	Negative	None
37	M	57	16	Intra-abdominal bleeding	Negative	None
38	F	68	7	Intra-abdominal bleeding	Right hepatic artery	Microcoil embolization of the posterior branch of the right hepatic artery

表2

图1

图2

参考文献 13

[1]	CAREY L C. Pancreaticoduodenectomy[J]. Am J Surg, 1992, 164(2):153-162. pmid: 1353323
[2]	SIMON R. Complications after pancreaticoduodenectomy[J]. Surg Clin North Am, 2021, 101(5):865-874. doi: 10.1016/j.suc.2021.06.011 pmid: 34537148
[3]	FARVACQUE G, GUILBAUD T, LOUNDOU A D, et al. Delayed post-pancreatectomy hemorrhage and bleeding recurrence after percutaneous endovascular treatment: risk factors from a bi-centric study of 307 consecutive patients[J]. Langenbecks Arch Surg, 2021, 406(6):1893-1902.
[4]	GOEV A A, BERELAVICHUS S V, KARCHAKOV S S, et al. Postpancreatectomy hemorrhage[J]. Khirurgiia(Mosk), 2021,(1):77-82.
[5]	RAJENDRAN J, PANWAR R, SINGH A N, et al. Ma-nagement and outcomes of pseudoaneurysms presenting with late hemorrhage following pancreatic surgery: a six-year experience from a tertiary care center[J]. Indian J Gastroenterol, 2023, 42(3):361-369.
[6]	李伟, 吴胜, 田宇剑, 等. 胰十二指肠切除术后腹腔内出血的相关因素分析及预防策略[J]. 外科理论与实践, 2024, 29(3):243-248.
	LI W, WU S, TIAN Y J, et al. Analysis of risk factors and preventive strategies for intra-abdominal hemorrhage after pancreaticoduodenectomy[J]. J Surg Concepts Pract, 2024, 29(3):243-248.
[7]	ROY-CHOUDHURY S H, GALLACHER D J, PILMER J, et al. Relative threshold of detection of active arterial bleeding: in vitro comparison of MDCT and digital subtraction angiography[J]. Am J Roentgenol, 2007, 189(5):W238-W246.
[8]	ZHOU T Y, SUN J H, ZHANG Y L, et al. Post-pancreaticoduodenectomy hemorrhage: DSA diagnosis and endovascular treatment[J]. Oncotarget, 2017, 8(43):73684-73692.
[9]	WENTE M N, VEIT J A, BASSI C, et al. Postpancreatectomy hemorrhage (PPH): an international study group of pancreatic surgery (ISGPS) definition[J]. Surgery, 2007, 142(1):20-25.
[10]	URBANO J, MANUEL CABRERA J, FRANCO A, et al. Selective arterial embolization with ethylene-vinyl alcohol copolymer for control of massive lower gastrointestinal bleeding: feasibility and initial experience[J]. J Vasc Interv Radiol, 2014, 25(6):839-846. doi: 10.1016/j.jvir.2014.02.024 pmid: 24755085
[11]	STAERKLE R F, VUILLE-DIT-BILLE R N, SOLL C, et al. Extended lymph node resection versus standard resection for pancreatic and periampullary adenocarcinoma[J]. Cochrane Database Syst Rev, 2021, 1(1):CD11490.
[12]	REDDY J R, SAXENA R, SINGH R K, et al. Reoperation following pancreaticoduodenectomy[J]. Int J Surg Oncol,2012, 2012:218248
[13]	韩序, 楼文晖, 刘亮. 胰十二指肠切除术后出血的治疗决策及预防措施[J]. 中华普通外科杂志, 2023, 38(5):377-382.
	HAN X, LOU W H, LIU L. Treatment strategies and preventive measures for post-pancreaticoduodenectomy hemorrhage[J]. Chin J Gen Surg, 2023, 38(5):377-382.

Item	Category	Number of Patients
Gender	Male	28
Gender	Female	10
Age（years）	<60	8
	60 ‒ 69	17
	≥70	13
Diagnosis	Distal bile duct adenocarcinoma	5
	Duodenal papillary adenocarcinoma	23
	Pancreatic ductal adenocarcinoma	9
	Other ampullary diseases	1
Time of bleeding	< 1 week	4
	1‒2 weeks	24
	>2 weeks	10
Bleeding manifestation	Gastrointestinal bleeding	9
	Intra-abdominal bleeding	25
	Gastrointestinal + intra-abdominal bleeding	4

[1]	张海钰, 仲海燕, 陈勇, 等. 腓肠内、外侧动脉的DSA观察及其在皮瓣移植中的应用[J]. 组织工程与重建外科杂志, 2025, 21(2): 119-.
[2]	张健, 钱伟清, 衣晓蕾. 超声造影对下腔静脉滤器血栓的诊断价值[J]. 外科理论与实践, 2024, 29(05): 441-445.
[3]	李伟, 吴胜, 田宇剑, 唐晓明, 蔡创, 许志伟. 胰十二指肠切除术后腹腔内出血的相关因素分析及预防策略[J]. 外科理论与实践, 2024, 29(03): 243-248.
[4]	王美文, 傅宁稹, 王伟珅, 任新平. 胰十二指肠联合静脉切除重建术后早期血管栓塞的床旁超声诊断及危险因素分析[J]. 外科理论与实践, 2024, 29(01): 54-60.
[5]	华杰, 施思, 孟庆才, 许航, 刘江, 梁晨, 王巍. 改良“双U法胰肠吻合”在胰十二指肠切除术的运用及效果评估[J]. 外科理论与实践, 2024, 29(01): 34-39.
[6]	董元航, 陈洁. 胰十二指肠切除术后胆胰疾病消化内镜介入策略[J]. 外科理论与实践, 2023, 28(04): 307-309.
[7]	于岚, 张永怡, 黄雷, 万歆, 姜胜耀, 唐思静, 张俊, 胡伟国. 老年病人胰十二指肠切除术后严重并发症发生的危险因素[J]. 外科理论与实践, 2023, 28(02): 139-146.
[8]	谢学海, 杨尹默. 胰肠吻合术式评价及技术要点[J]. 外科理论与实践, 2022, 27(01): 1-5.
[9]	徐煜, 张军峰, 花荣. 奥曲肽预防胰十二指肠切除术后胰漏的研究进展[J]. 外科理论与实践, 2022, 27(01): 83-86.
[10]	沈展涛, 刘一峰, 谭志健, 钟小生. 腹腔镜胰十二指肠切除术小胆管行胆肠吻合的策略与技术[J]. 外科理论与实践, 2022, 27(01): 39-41.
[11]	王巍, 华杰. 胰十二指肠切除术中常见血管变异及应对策略[J]. 外科理论与实践, 2022, 27(01): 34-38.
[12]	陈丹磊, 邵成浩. 远端胆管癌微创治疗的争议与技术要点[J]. 外科理论与实践, 2021, 26(02): 120-123.
[13]	梁贇, 姜翀弋, 赵丽亭, 王宏伟, 胡鹏飞, 蔡志伟, 王巍. 腹腔镜胰十二指肠切除术在老年病人中的可行性分析[J]. 外科理论与实践, 2020, 25(01): 60-64.
[14]	王贺彬, 彭丰, 朱峰, 王敏, 秦仁义. 腹腔镜与开腹胰十二指肠切除术近期临床疗效评价[J]. 外科理论与实践, 2019, 24(03): 222-225.
[15]	林捷威, 王伟珅, 沈柏用. 胰十二指肠切除术后胰漏相关危险因素及其预防[J]. 外科理论与实践, 2019, 24(03): 271-275.