经导管动脉栓塞在外科手术和非外科手术后重症急性胰腺炎伴出血中的应用
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摘要
目的探讨经导管动脉栓塞术(TAE)在外科手术和非外科手术后重症急性胰腺炎(SAP)伴出血患者中的应用。方法收集2013年2月至2018年2月收治的35例SAP患者临床资料,所有患者均经TAE术中证实为动脉破裂出血或假性动脉瘤形成。TAE术前患者分为两组,已接受外科手术治疗患者14例为A组,未接受外科手术患者21例为B组。分析两组患者影像学特点、临床表现及TAE术疗效。结果影像学检查显示,A组6例(43%,6/14)肠瘘,明显多于B组(P<0.05)。临床检查显示,A组14例(100%,14/14)腹腔引流管出血,6例(43%,6/14)突发性低血压,均明显多于B组(P<0.05);B组6例血便(29%,6/21),明显多于A组(P<0.05)。TAE术疗效显示,两组患者总栓塞成功率为95%(37/39),出血复发率为11%(4/35),其中3例出血点不同于首次造影,均再次成功栓塞;术后A组1例出现肝脓肿,B组1例出现脾脓肿,均经腹腔引流和抗感染好转;两组总死亡率为9%(3/35)。结论 TAE术前已接受外科手术和未接受外科手术治疗SAP伴出血患者影像学特点和临床表现有一定差异,但TAE术对这两组患者止血率高、死亡率低,可作为临床处理SAP伴动脉出血首选方法。
Objective To discuss the application of transcatheter arterial embolization(TAE) in treating severe acute pancreatitis(SAP) associated with bleeding after surgical or non-surgical treatment.Methods The clinical data of 35 patients with SAP, who were admitted to authors' hospital during the period from February 2013 to February 2018, were collected. All patients had arterial rupture bleeding or pseudoaneurysm, which was confirmed by angiography during TAE procedure. The patients were divided into surgical group(n=14) and non-surgical group(n=21) according to the therapy the patient accepted before TAE. The imaging features, clinical manifestations and the curative effect of TAE of both groups were analyzed. Results Imaging examination showed that the incidence of intestinal fistula in the surgical group was 43%(6/14), which was significantly higher than 0%(0/21) in the non-surgical group(P<0.05). Clinical examination indicated that in the surgical group hemorrhage from the abdominal drainage tube was seen in 14 patients(100%) and sudden hypotension in 6 patients(43%), which were remarkably more than those in the non-surgical group(P<0.05). In the non-surgical group the incidence of bloody stool was 29%(6/21), which was strikingly higher than that in the surgical group(P<0.05). A total of 39 procedures of TAE were performed in the 35 patients, the technical success rate was 95%(37/39). The total bleeding recurrence rate was 11%(4/35), and in 3 patients the recurrent bleeding site was different from the previous bleeding site demonstrated on the initial angiography, and the bleeding was successfully stopped by repeated TAE. In the surgical group one patient developed liver abscess, and in the non-surgical group one patient developed splenic abscess, the clinical symptoms were improved in both patients after anti-infection and catheter drainage treatment. The total mortality of two groups after TAE was 9%(3/35). Conclusion Certain differences in imaging features and clinical manifestations exist between the SAP patients who received surgical therapy before TAE and the SAP patients who did not receive surgical therapy before TAE. But TAE has higher hemostatic rate and lower mortality in the patients of both groups. Therefore, TAE can be used as the first choice for clinical treatment of SAP associated with arterial hemorrhage.(J Intervent Radiol, 2019,28: 379-382)
Objective To discuss the application of transcatheter arterial embolization(TAE) in treating severe acute pancreatitis(SAP) associated with bleeding after surgical or non-surgical treatment.Methods The clinical data of 35 patients with SAP, who were admitted to authors' hospital during the period from February 2013 to February 2018, were collected. All patients had arterial rupture bleeding or pseudoaneurysm, which was confirmed by angiography during TAE procedure. The patients were divided into surgical group(n=14) and non-surgical group(n=21) according to the therapy the patient accepted before TAE. The imaging features, clinical manifestations and the curative effect of TAE of both groups were analyzed. Results Imaging examination showed that the incidence of intestinal fistula in the surgical group was 43%(6/14), which was significantly higher than 0%(0/21) in the non-surgical group(P<0.05). Clinical examination indicated that in the surgical group hemorrhage from the abdominal drainage tube was seen in 14 patients(100%) and sudden hypotension in 6 patients(43%), which were remarkably more than those in the non-surgical group(P<0.05). In the non-surgical group the incidence of bloody stool was 29%(6/21), which was strikingly higher than that in the surgical group(P<0.05). A total of 39 procedures of TAE were performed in the 35 patients, the technical success rate was 95%(37/39). The total bleeding recurrence rate was 11%(4/35), and in 3 patients the recurrent bleeding site was different from the previous bleeding site demonstrated on the initial angiography, and the bleeding was successfully stopped by repeated TAE. In the surgical group one patient developed liver abscess, and in the non-surgical group one patient developed splenic abscess, the clinical symptoms were improved in both patients after anti-infection and catheter drainage treatment. The total mortality of two groups after TAE was 9%(3/35). Conclusion Certain differences in imaging features and clinical manifestations exist between the SAP patients who received surgical therapy before TAE and the SAP patients who did not receive surgical therapy before TAE. But TAE has higher hemostatic rate and lower mortality in the patients of both groups. Therefore, TAE can be used as the first choice for clinical treatment of SAP associated with arterial hemorrhage.(J Intervent Radiol, 2019,28: 379-382)
引文
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[4] Hyare H, Desigan S, Brookes JA, et al. Endovascular management of major arterial hemorrhage as a complication of inflammatory pancreatic disease[J]. J Vasc Interv Radiol, 2007, 18:591-596.
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[6] Banks PA, Bollen TL, Dervenis C, et al. Classification of acute pancreatitis:2012:revision of the Atlanta classification and definitions by international consensus[J]. Gut, 2013, 62:102-111.
[7] De Waele JJ. A step-up approach, or open necrosectomy for necrotizing pancreatitis[J]. N Engl J Med, 2010, 363:1286.
[8] Chen JF, Xu SF, Zhao W, et al. Diagnostic and therapeutic strategies to manage post-pancreaticoduodenectomy hemorrhage[J]. World J Surg, 2015, 39:509-515.
[9] Zyromski NJ, Vieira C, Stecker M, et al. Improved outcomes in postoperative and pancreatitis-related visceral pseudoaneurysms[J]. J Gastrointest Surg, 2007, 11:50-55.
[10] de Castro SM, Kuhlmann KF, Busch OR, et al. Delayed massive hemorrhage after pancreatic and biliary surgery:embolization or surgery?[J]. Ann Surg, 2005, 241:85-91.
[11] Barge JU, Lopera JE. Vascular complications of pancreatitis:role of interventional therapy[J]. Korean J Radiol, 2012, 13(Suppl1):S45-S55.
[12] Balachandra S, Siriwardena AK. Systematic appraisal of the management of the major vascular complications of pancreatitis[J]. Am J Surg, 2005, 190:489-495.
[13] Sethi H, Peddu P, Prachalias A, et al. Selective embolization for bleeding visceral artery pseudoaneurysms in patients with pancreatitis[J]. Hepatobiliary Pancreat Dis Int, 2010, 9:634-638.
[14] Boudghene F. L'hermine C, Bigot JM. Arterial complications of pancreatitis:diagnostic and therapeutic aspects in 104 cases[J].J Vasc Interv Radiol, 1993, 4:551-558.
[15] Chen Y, Zhou J, Li G, et al. Early spontaneous abdominal bleeding is associated with poor outcome in moderate to severe acute pancreatitis patients:a propensity matched study[J]. Sci Rep, 2017, 7:42607.
[2] Pupelis G, Fokin V, Zeiza K, et al. Focused open necrosectomy in necrotizing pancreatitis[J]. HPB(Oxford), 2013, 15:535-540.
[3] Marone EM, Mascia D, Kahlberg A, et al. Is open repair still the gold standard in visceral artery aneurysm management?[J].Ann Vasc Surg, 2011, 25:936-946.
[4] Hyare H, Desigan S, Brookes JA, et al. Endovascular management of major arterial hemorrhage as a complication of inflammatory pancreatic disease[J]. J Vasc Interv Radiol, 2007, 18:591-596.
[5]王勇,梁惠民,郑传胜,等.急性胰腺炎出血的血管造影诊断及经导管栓塞治疗[J].介入放射学杂志, 2006, 15:215-217.
[6] Banks PA, Bollen TL, Dervenis C, et al. Classification of acute pancreatitis:2012:revision of the Atlanta classification and definitions by international consensus[J]. Gut, 2013, 62:102-111.
[7] De Waele JJ. A step-up approach, or open necrosectomy for necrotizing pancreatitis[J]. N Engl J Med, 2010, 363:1286.
[8] Chen JF, Xu SF, Zhao W, et al. Diagnostic and therapeutic strategies to manage post-pancreaticoduodenectomy hemorrhage[J]. World J Surg, 2015, 39:509-515.
[9] Zyromski NJ, Vieira C, Stecker M, et al. Improved outcomes in postoperative and pancreatitis-related visceral pseudoaneurysms[J]. J Gastrointest Surg, 2007, 11:50-55.
[10] de Castro SM, Kuhlmann KF, Busch OR, et al. Delayed massive hemorrhage after pancreatic and biliary surgery:embolization or surgery?[J]. Ann Surg, 2005, 241:85-91.
[11] Barge JU, Lopera JE. Vascular complications of pancreatitis:role of interventional therapy[J]. Korean J Radiol, 2012, 13(Suppl1):S45-S55.
[12] Balachandra S, Siriwardena AK. Systematic appraisal of the management of the major vascular complications of pancreatitis[J]. Am J Surg, 2005, 190:489-495.
[13] Sethi H, Peddu P, Prachalias A, et al. Selective embolization for bleeding visceral artery pseudoaneurysms in patients with pancreatitis[J]. Hepatobiliary Pancreat Dis Int, 2010, 9:634-638.
[14] Boudghene F. L'hermine C, Bigot JM. Arterial complications of pancreatitis:diagnostic and therapeutic aspects in 104 cases[J].J Vasc Interv Radiol, 1993, 4:551-558.
[15] Chen Y, Zhou J, Li G, et al. Early spontaneous abdominal bleeding is associated with poor outcome in moderate to severe acute pancreatitis patients:a propensity matched study[J]. Sci Rep, 2017, 7:42607.