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

doi:10.16139/j.1007-9610.2024.03.10

摘要/Abstract

摘要：

目的：探讨胰十二指肠切除术后出血的相关因素及预防策略。方法：中国人民解放军联勤保障部队第九〇四医院肝胆外科2017年1月至2021年12月期间住院行胰十二指肠切除术的病人共计208例，其中出现术后出血21例，对其进行回顾性分析。结果：单因素分析表明，21例病人术后出血主要与胰漏、胆汁漏、腹腔感染、低蛋白血症、糖尿病、超声刀使用不当、骨骼化清扫、术中出血量、术前黄疸水平等有关（P<0.05），而与性别及年龄无关（P>0.05）。其中，4例经止血、输血等保守治疗后痊愈，6例行介入栓塞止血，11例行剖腹探查止血，其中2例术后出现多脏器功能衰竭死亡。胰漏（OR=3.963,95%CI: 1.120~14.025）、胆汁漏（OR=4.013,95% CI: 1.173~13.734）、腹腔感染（OR=7.545,95% CI: 1.833~31.051）是术后出血的独立危险因素。结论：不断提高吻合技术，减少吻合口漏，预防和控制腹腔感染，是预防胰十二指肠切除术后出血的主要措施。对术后出血保守治疗效果不佳的病人，应及时行手术治疗。

关键词: 胰十二指肠切除术, 术后出血, 相关因素, 预防

Abstract:

Objective To investigate the risk factors and preventive strategies of pancreaticoduodenectomy postoperative hemorrhage. Methods A total of 208 patients who underwent pancreaticoduodenectomy in the Department of Hepatobiliary Surgery of the 904th Hospital of Joint Logistics Support Force, PLA from January 2017 to December 2021 were enrolled. Twenty-one patients with postoperative hemorrhage were retrospectively analyzed. Results Univariate analysis indicated that postoperative hemorrhage was mainly associated with pancreatic leakage, biliary leakage, abdominal infection, hypoproteinemia, diabetes, improper use of ultrasound knife, skeletonization, intraoperative blood loss, preoperative jaundice, etc.(P<0.05), but not gender and age (P>0.05). Among the 21 patients with postoperative hemorrhage, 4 cases recovered after conservative treatment such as hemostasis and blood transfusion, 6 cases underwent interventional treatment, 11 cases underwent abdominal exploration, and 2 cases died of postoperative multiple organ failure. Pancreatic leakage (OR=3.963,95%CI: 1.120-14.025), biliary leakage (OR=4.013,95% CI: 1.173-13.734) and abdominal infection (OR=7.545,95%CI: 1.833-31.051) were independent risk factors for postoperative hemorrhage. Conclusions The improvement of anastomotic manipulation, reduction of anastomotic leakage, and control and prevention of abdominal infection are important to prevent postoperative hemorrhage of pancreaticoduodenectomy. Surgical treatment should be performed as soon as possible for the patients with poor conservative treatment effect.

Key words: Pancreaticoduodenectomy, Postoperative bleeding, Related factors, Prevention

中图分类号:

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.

LI Wei, WU Sheng, TIAN Yujian, TANG Xiaoming, CAI Chuang, XU Zhiwei. Risk factors and prevention strategies for intraperitoneal hemorrhage after pancreaticoduodenectomy[J]. Journal of Surgery Concepts & Practice, 2024, 29(03): 243-248.

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参考文献 20

[1]	沈先锋, 兰浩铭, 胡军, 等. 胰十二指肠切除术后腹腔出血的危险因素分析[J]. 中国现代普通外科进展, 2021, 24(4):299-301.
	SHEN X F, LAN H M, HU J, et al. Analysis of risk factors for abdominal hemorrhage after pancreaticoduodenectomy[J]. Chin J Curr Adv Gen Surg, 2021, 24(4):299-301.
[2]	KASUMOVA G G, ESKANDER M F, KENT T S, et al. Hemorrhage after pancreaticoduodenectomy: does timing matter[J]. HPB (Oxford), 2016, 18(10):861-869.
[3]	郑强, 李生伟. 胰十二指肠切除术后出血相关危险因素分析[J]. 世界最新医学信息文摘(连续型电子期刊), 2021, 21(26):72-74.
	ZHENG Q, LI S W. Analysis of risk factors of postpancreatectomy hemorrhage after pancreaticoduodenectomy[J]. World Latest Med Inf (Electronic Version), 2021, 21(26):72-74.
[4]	SMITS F J, VERWEIJ M E, DAAMEN L A, et al. Impact of complications after panereatoduodenectomy on mortali-ty, organ failure, hospital stay, and readmission:analysis of a nationwide audit[J]. Ann Surg, 2022, 275(1):e222-e228.
[5]	WENTE M N, VEIT J A, BASSI C, et al. Postpancrealectomy hemorrhage(PPH):an international study group of pancreatic surgery(ISGPS)definition[J]. Surgery, 2007, 142(1):20-25.
[6]	徐洪, 毛晓泉, 李建才, 等. 参麦注射液对限制性液体复苏损伤控制性手术下创伤失血性休克患者疗效评价[J]. 山西医药杂志, 2022, 51(18):2122-2125.
	XU H, MAO X Q, LI J C, et al. Therapeutic effect of Shenmai Injection on patients with traumatic hemorrhagic shock after restricted fluid resuscitation injury control operation[J]. Shanxi Med J, 2022, 51(18):2122-2125.
[7]	BRODSKY J T, TURNBULL A D. Arterial hemorrhage after pancreatoduodenectomy. The “sentinel bleed”[J]. Arch Surg, 1991, 126(8):1037-1040.
[8]	张树彬, 周新博, 胡子轩, 等. 肝左外叶及左尾状叶包裹胃十二指肠动脉残端预防腹腔镜胰十二指肠切除术后出血的初步研究[J]. 中华外科杂志, 2023, 61(2):145-149.
	ZHANG S B, ZHOU X B, HU Z X, et al. A preliminary study on the prevention of hemorrhage after laparoscopic pancreaticoduodenectomy by wrapping gastroduodenal artery stump in the left external liver lobe and the left caudate lobe[J]. Chin J Surg, 2023, 61(2):145-149.
[9]	王军武, 冉崇福. 纳米碳混悬液在甲状腺肿瘤手术中对甲状旁腺保护作用的研究[J]. 西南国防医药, 2014, 12(6):609-612.
	WANG J W, RAN C F. Protective effects of carbon nanoparticles on parathyroid in thyroid surgery[J]. Med J Nat Defending Forces Southwest China, 2014, 12(6):609-612.
[10]	WELLNER U F, KULEMANN B, LAPSHYN H, et al. Postpancreatectomy hemorrhage—incidence, treatment, and risk factors in over 1,000 pancreatic resections[J]. J Gastrointest Surg, 2014, 18(3):464-475.
[11]	PUPPALA S, PATEL J, MCPHERSON S, et al. Hemorrhagic complications after whipple surgery: imaging and radiologic intervention[J]. Am J Roentgenol, 2011, 196(1):192-197. doi: 10.2214/AJR.10.4727 pmid: 21178067
[12]	唐荣, 周开伦, 李灼日, 等. 胰十二指肠切除术后出血原因分析[J]. 中华普通外科杂志, 2015, 30(12):972-974.
	TANG R, ZHOU K L, LI Z R, et al. Postoperative bleeding after pancreaticoduodenectomy[J]. Chin J Gen Surg, 2015, 30(12):972-974.
[13]	WATANABE F, NODA H, KAMIYAMA H, et al. Risk factors for intra-abdominal infection after pancreaticoduodeneetomy—a retrospective analysis to evaluate the significance of preoperative biliary drainage and postoperative pancreatic fistula[J]. Hepatogastroentemlogy, 2012, 59(116):1270-1273.
[14]	陈友谊, 孙备, 姜洪池. 胰十二指肠切除术后胰瘘的影响因素分析[J]. 中华外科杂志, 2013, 51(8):680-684.
	CHEN Y Y, SUN B, JIANG H C. Analysis of influencing factors of pancreatic fistula after pancreaticoduodenectomy[J]. Chin J Surg, 2013, 51(8):680-684.
[15]	李国光, 成伟, 陈梅福, 等. 腹腔镜胰十二指肠切除术后出血的相关分析与总结[J]. 中华肝胆外科杂志, 2021, 27(6):425-428.
	LI G G, CHENG W, CHEN M F, et al. Postoperative hemorrhage after laparoscopic pancreaticoduodenectomy[J]. Chin J Hepatobiliary Surg, 2021, 27(6):425-428.
[16]	钟云萍, 张宏宇, 戴海粟, 等. 胰十二指肠切除术后出血的危险因素分析及列线图预测模型建立[J]. 肝胆外科杂志, 2022, 30(4):276-280.
	ZHONG Y P, ZHANG H Y, DAI H S, et al. Risk factors analysis and prediction model of postpancreaticoduodenectomy hemorrhage[J]. J Hepatobiliary Surg, 2022, 30(4):276-280.
[17]	马永蔌, 杨尹默. 胰十二指肠切除术后出血相关热点问题探讨[J]. 肝胆外科杂志, 2022, 30(4):246-250.
	MA Y S, YANG Y M. Discussion on hot issues related to bleeding after pancreaticoduodenectomy[J]. J Hepatobi-liary Surg, 2022, 30(4):246-250.
[18]	NICKEL F, LANG F, KOWALEWSKI K F, et al. Pancreatic surgery with or without drainage:propensity score-matched study[J]. Br J Surg, 2022, 109(8):739-745.
[19]	WANG M, LI D, CHEN R, et al. Laparoscopie versus open pancreatoduodenectomy for pancreatic or periampullary tumours:a muhicentre, open-label, randomised controlled trial[J]. Lancet Gastroenterol Hepatol, 2021, 6(6):438-447.
[20]	STAERKLE R F, VUILLE-DIT-BILLE R N, SOLL C, et al. Extended lymphnode resection versus standard resection for pancreatic and periampullary adenocarcinoma[J]. Cochrane Database Syst Rev, 2021, 1(1):Cd011490.

Indicator	Group	Postoperative hemorrhage		χ² value	P value
Indicator	Group	Yes(n=21)	No(n=187)	χ² value	P value
Age	<60 years	9(42.9)	104(55.6)	1.238	0.266
	≥60 years	12(57.1)	83(44.4)
Sex	Female	9(42.9)	87(46.5)	0.102	0.749
	Male	12(57.1)	100(53.5)
Mean post- operative serum glucose levels	≥10 mmol/L	13(61.9)	73(39.0)	4.071	0.044
Mean post- operative serum glucose levels	<10 mmol/L	8(38.1)	114(61.0)
Postoperative hypoproteinemia	<30 g/L	13(61.9)	70(37.4)	4.715	0.030
Postoperative hypoproteinemia	≥30 g/L	8(38.1)	117(62.6)
Skeletonization	Yes	13(61.9)	67(35.8)	5.424	0.020
	No	8(38.1)	120(64.2)
Pancreatic leakage	Yes	16(76.2)	82(43.9)	7.925	0.005
Pancreatic leakage	No	5(23.8)	105(56.1)
Biliary leakage	Yes	14(66.7)	76(40.6)	5.209	0.022
	No	7(33.3)	111(59.4)
Abdominal infection	Yes	17(81.0)	94(50.3)	7.143	0.008
Abdominal infection	No	4(19.0)	93(49.7)
Improper use of ultrasound knife	Yes	14(66.7)	74(39.6)	5.678	0.017
Improper use of ultrasound knife	No	7(33.3)	113(60.4)
Intraoperative blood loss	≥800 mL	13(61.9)	72(38.5)	4.279	0.039
Intraoperative blood loss	<800 mL	8(38.1)	115(61.5)
Preoperative total bilirubin	≥171 mmol/L	16(76.2)	90(48.1)	5.949	0.015
Preoperative total bilirubin	<171 mmol/L	5(23.8)	97(51.9)

Item	Indicator	Assignment
Dependent variable	Postoperative hemorrhage	Yes=1, No=2
Independent variable	Sex	Male=1, Female=0
	Age	Under 60 years old=1, No less than 60 years old=2
	Mean postoperative serum glucose levels	≥10 mmol/L=1, <10 mmol/L=2
	Postoperative hypoproteinemia	<30 g/L=1, ≥30 g/L=2
	Skeletonized lymph node dissection	Yes=1, No=2
	Pancreatic leakage	Yes=1, No=2
	Biliary leakage	Yes=1, No=2
	Abdominal infection	Yes=1, No=2
	Improper use of ultrasound knife	Yes=1, No=2
	Intraoperative blood loss	≥800 mL=1, <800 mL=2
	Preoperative total bilirubin	≥171 mmol/L=1, <171 mmol/L=2

Item	B	SE	wald	P value	OR value（95%CI）
Mean postoperative serum glucose levels	0.726	0.565	1.651	0.199	2.068(0.683-6.262)
Postoperative hypoproteinemia	1.032	0.618	2.792	0.095	2.807(0.836-9.420)
Skeletonized lymph node dissection	0.737	0.568	1.681	0.195	2.089(0.686-6.362)
Pancreatic leakage	1.377	0.645	4.562	0.033	3.963(1.120-14.025)
Biliary leakage	1.390	0.628	4.901	0.027	4.013(1.173-13.734)
Abdominal infection	2.021	0.722	7.838	0.005	7.545(1.833-31.05)
Improper use of ultrasound knife	1.015	0.580	3.069	0.080	2.761(0.886-8.598)
Intraoperative blood loss	0.990	0.603	2.698	0.100	2.691(0.826-8.768)
Preoperative total bilirubin	1.163	0.635	3.354	0.067	3.199(0.922-11.107)