胆道术后假性动脉瘤破裂出血14例诊治分析

摘要

目的 探讨胆道术后假性动脉瘤破裂出血的诊治方法及预防.方法 回顾性分析解放军总医院肝胆外科2002年1月至2012年3月收治的14例胆道术后假性动脉瘤破裂出血患者的临床资料.14例患者猝死4例,其余10例按不同诊断治疗方法分为3组:出血后保守治疗组2例；出血后立即行剖腹探查、止血术组5例；出血后立即行选择性数字减影血管造影(DSA)检查及介入栓塞(TAE)治疗组3例.对其诊治要点及预防措施进行探讨.结果 本组病例死亡6例,治愈8例.保守治疗2例均失败(100％),后均接受DSA检查及TAE治疗,1例死亡;剖腹探查、止血5例,2例确诊(40％)后治愈(40％),余3例术后又接受DSA检查及TAE治疗,1例死亡；出血后立即行选择性DSA检查及TAE治疗组3例,确诊3例(100％),治愈3例(100％).所有病例共行选择性DSA检查8例,确诊8例(100％),经TAE治疗9次(8例),有效8次(89％),治愈6例(75％)；其中经2次TAE治疗1例,死亡2例.死亡病例中4例猝死,1例为2次TAE治疗后肝功能衰竭死亡,另1例为剖腹转栓塞止血后多脏器功能衰竭死亡.结论 胆道术后假性动脉瘤破裂出血应早期诊断、早期治疗.选择性DSA检查是本病的首选诊断方法.TAE治疗应作为本病的首选治疗方法.胆道术后假性动脉瘤的形成与手术操作有关,应重在预防.%Objective To investigate the diagnosis,treatment,and prevention of hemobilia from ruptured false aneurysms after hepatobiliary surgery.Methods A retrospective analysis was performed on the clinical data of 14 patients with hemobilia from ruptured false aneurysms after hepatobiliary surgery who were admitted to Department of Hepatobiliary Surgery,Chinese PLA General Hospital from January 2002 to March 2012.These patients were divided into three groups to receive conservative treatment,exploratory laparotomy and hemostasis (done immediately after hemobilia),or selective digital subtraction angiography (DSA) and transhepatic arterial embolization (TAE) (done immediately after hemobilia).The key points of diagnosis and treatment and preventive measures were investigated.Results Of the 14 patients,6 died,and 8 were cured.Conservative treatment was performed in 2 patients,but failed in both of them (100％) ; then,the 2 cases underwent DSA and received TAE,and one of them died.Five patients received exploratory laparotomy and hemostasis; 2 cases (40％) were cured after confirmed diagnosis,and the other 3 cases then underwent DSA and received TAE after operation,with one dead.Three patients received selective DSA and TAE immediately after hemobilia; all the 3 cases (100％) had a confirmed diagnosis and were cured.Selective DSA was performed in 8 patients,and all (100％) of them had a confirmed diagnosis.TAE was done 9 times in 8 patients,and 8 times (89％) of TAE were effective; 6 cases (75％) were cured,1 case received TAE twice,and 2 cases died after TAE.Of all the dead cases,4 suffered sudden death,1 died of liver failure after 2 times TAE,and 1 died of multiple organ failure after laparotomy and TAE.Conclusion Early diagnosis and treatment are essential for hemobilia from ruptured false aneurysms after hepatobiliary surgery ; selective DSA is the optimal diagnostic method,and TAE should be the first choice of treatment.The formation of false aneurysms after hepatobiliary surgery is related to surgical operation,and more attention should be directed to prevention.