摘要目的 总结胰十二指肠切除术(PD)后迟发性出血(DMH)的诊疗经验和文献观点,提高对该并发症的诊治水平.方法 对解放军总医院14例DMH患者的临床数据进行回顾性分析,初步分析其危险因素,并对不同治疗方式的效果进行比较.结果 1993年3月-2011年4月共有1008例患者于解放军总医院肝胆外科进行PD术,术后DMH患者14例(1.4％).其中10例曾发生胰瘘.DMH发生前10例患者发生先兆出血.DMH表现为单纯腹腔出血6例,消化道出血3例,腹腔+消化道出血3例,低血压休克2例.13例患者止血成功,1例患者于院外未及救治病死.止血方式中,采用介入治疗者8例(n=8),开腹手术者5例(n=5).组间比较止血后再出血例数、止血后并发症发生例数和病死例数分别为4例与2例(P=0.83),6例与2例(P=0.96)和4例与2例(P=0.62).最终5例患者救治成功.结论 DMH是PD术后少见的严重并发症,诊治困难,病死率高.胰瘘可能是其危险因素,先兆出血是预测DMH发生的重要征象,常规行动脉造影检查是早期诊断,提高救治成功率的有效方法.

abstractsObjective To summarize our clinical experiences of delayed massive hemorrhagc (DMH),a rare but fatal complication,after pancreaticoduodenectomy (PD).Methods The clinical data of 14 DMH patients at our medical center were collected and analyzed to evaluate the risk factors and to compare the efficacies of different therapies.Results A total of 1008 PD patients were treated since April 1993.Fourteen DMHs occurred post-operatively (1.4％).In these cases,10/14 (71.4％) were complicated with pancreatic fistula. Sentinel bleeding was observed in 10 (71.4％) cases.The clinical manifestations of DMH included simple abdominal hemorrhage (n =6,42.9％ ), alimentary tract hemorrhage (n =6,42.9％ ) and both (n =3,21.4％ ).Shock (n =2,14.3％ ) might also be the initial symptom.Thirteen cases achieved post-therapeutic hemostasis while 1 patient died before re-admission.The therapeutic modalities included interventional therapy ( n =8 ) and surgery ( n =5 ).According to the therapeutic modalities,the re-bleeding rate,morbidity and final mortality of two groups were 50.0％ vs 40.0％ ( P =0.83 ),75.0％ vs 60.0％ ( P =0.96 ) and 50.0％ vs 80.0％ ( P =0.62) respectively.Five patients survived at the end of treatment.The mortality rate was 71.4％.Conclusion As a rare but fatal complication after PD,DMH is difficult to diagnose and treat.Postoperative pancreatic fistula remains a possible but undetermined risk factor. Sentinel bleeding is of great predicative value for DMH. Regular interventional arteriography is an effective method of improving diagnosis and treatment.Both interventional therapy and surgery may be used to treat DMH.