Risk factors for intraoperative massive hemorrhage in patients with pancreatitis-induced sinistral portal hypertension_CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY

Authors：

SONG Haiyu , TAN Qingquan , CHEN Yonghua , WANG Xing , TAN Chunlu ,  LIU Xubao

Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu 610041, P. R. China;

Corresponding?author：

LIU Xubao, Email: xbliu@medmail.com.cn

Keywords：

sinistral portal hypertension; acute pancreatitis; chronic pancreatitis; splenectomy; gastric varices

DOI：

10.7507/1007-9424.201812025

Video：

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Objective To analyze risk factors of intraoperative massive hemorrhage in patients with pancreatitis-induced sinistral portal hypertension (SPH) and to explore its strategies of treatment.Methods The clinical data of patients with pancreatitis-induced SPH admitted to the West China Hospital of Sichuan University from January 2015 to March 2018 were retrospectively analyzed. The intraoperative massive hemorrhage was defined as the blood loss exceeding 30% blood volume. The factors closely associated with the intraoperative massive hemorrhage were analyzed by the forward logistic regression model.Results A total of 128 patients with pancreatitis-induced SPH were enrolled in this study, including 104 males and 24 females, with an average age of 47 years old and a median intraoperative bleeding volume of 482 mL. Among them, 93 patients with pancreatitis-induced SPH caused by the pancreatic pseudocyst after acute pancreatitis and 35 caused by the chronic pancreatitis. There were 36 patients with history of upper gastrointestinal bleeding and 46 patients with hypersplenism. Thirty-six patients suffered from the massive hemorrhage. Among them, 30 patients underwent the distal pancreatectomy concomitant with splenectomy, 1 patient underwent the duodenum- preserving resection of pancreatic head, and 5 patients underwent the pseudocyst drainage. The univariate analysis showed that the occurrence of intraoperative massive hemorrhage in the patients with pancreatitis-induced SPH was not associated with the gender, age, body mass index, albumin level, upper gastrointestinal bleeding, hypersplenism, type of pancreatitis, course of pancreatitis, number of attacks of pancreatitis, size of spleen, maximum diameter of lesions in the splenic vein obstruction site, or number of operation (P>0.05), which was associated with the diameter of varicose vein more than 5.0 mm (χ²=19.83, P<0.01), the intraperitoneal varices regions (χ²=13.67, P<0.01), the location of splenic vein obstruction (χ²=5.17, P=0.03), the operation time (t=–3.10, P<0.01), or the splenectomy (χ²=17.46, P<0.01). Further the logistic regression analysis showed that the varicose vein diameter more than 5.0 mm (OR=6.356, P=0.002) and splenectomy (OR=4.297, P=0.005) were the independent risk factors for the intraoperative massive hemorrhage in the patients with pancreatitis-induced SPH.Conclusions Splenectomy and having a collateral vein more than 5.0 mm in diameter are independent risk factors for intraoperative massive blood loss in surgeries taken on patients with pancreatitis-induced SPH. Attention should be paid to dilation of gastric varices and choice of splenectomy.

Citation： SONG Haiyu, TAN Qingquan, CHEN Yonghua, WANG Xing, TAN Chunlu, LIU Xubao. Risk factors for intraoperative massive hemorrhage in patients with pancreatitis-induced sinistral portal hypertension. CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY, 2019, 26(5): 557-562. doi: 10.7507/1007-9424.201812025 Copy

1.	竇科峰, 于恒超. 胰源性門脈高壓癥. 肝膽外科雜志, 2009, 17(2): 83-84.
2.	Heider TR, Azeem S, Galanko JA, et al. The natural history of pancreatitis-induced splenic vein thrombosis. Ann Surg, 2004, 239(6): 876-882.
3.	吳苾, 宋彬, 陳衛霞. 胰源性區域性門靜脈高壓的螺旋CT表現及臨床意義. 中國醫學影像技術, 2004, 20(9): 1461-1464.
4.	Fernandes A, Almeida N, Ferreira AM, et al. Left-sided portal hypertension: a sinister entity. GE Port J Gastroenterol, 2015, 22(6): 234-239.
5.	Butler JR, Eckert GJ, Zyromski NJ, et al. Natural history of pancreatitis-induced splenic vein thrombosis: a systematic review and meta-analysis of its incidence and rate of gastrointestinal bleeding. HPB (Oxford), 2011, 13(12): 839-845.
6.	K?klü S, Coban S, Yüksel O, et al. Left-sided portal hypertension. Dig Dis Sci, 2007, 52(5): 1141-1149.
7.	張月寧, 錢家鳴, 陸星華, 等. 胰腺疾病相關性門脈高壓癥59例臨床分析. 中華消化雜志, 2006, 26(11): 721-725.
8.	趙欣, 雷澤華, 高峰畏, 等. 胰源性門靜脈高壓癥并上消化道出血的診治體會. 中國普外基礎與臨床雜志, 2019, 26(3): 348-350.
9.	Adams DB, Mauterer DJ, Vujic IJ, et al. Preoperative control of splenic artery inflow in patients with splenic venous occlusion. South Med J, 1990, 83(9): 1021-1024.
10.	Banks PA, Bollen TL, Dervenis C, et al. Classification of acute pancreatitis—2012: revision of the Atlanta classification and definitions by international consensus. Gut, 2013, 62(1): 102-111.
11.	中華醫學會外科學分會胰腺外科學組. 慢性胰腺炎診治指南(2014). 中華外科雜志, 2015, 53(4): 241-246.
12.	王錦萍, 崔毅, 王錦輝, 等. 上消化道出血15年臨床流行病學變化趨勢. 中華胃腸外科雜志, 2017, 20(4): 425-431.
13.	Jia R, Li N, Xu BY, et al. Incidence, influencing factors, and prognostic impact of intraoperative massive blood loss in adolescents with neuromuscular scoliosis: A STROBE-compliant retrospective observational analysis. Medicine (Baltimore), 2017, 96(11): e6292.
14.	盧山, 陸慧敏, 張凌, 等. 胰腺假性囊腫致左側門靜脈高壓伴脾臟功能亢進的處理策略探討. 中國普外基礎與臨床雜志, 2018, 25(5): 553-558.
15.	廖刃, 劉進. 圍手術期血液管理: 由限制性輸血走向個體化輸血. 中華醫學雜志, 2014, 94(7): 481-482.
16.	Nadler SB, Hidalgo JH, Bloch T. Prediction of blood volume in normal human adults. Surgery, 1962, 51(2): 224-232.
17.	Gross JB. Estimating allowable blood loss: corrected for dilution. Anesthesiology, 1983, 58(3): 277-280.
18.	Ejaz A, Spolverato G, Kim Y, et al. Variation in triggers and use of perioperative blood transfusion in major gastrointestinal surgery. Br J Surg, 2014, 101(11): 1424-1433.
19.	Marchegiani G, Andrianello S, Pieretti-Vanmarcke R, et al. Hospital readmission after distal pancreatectomy is predicted by specific intra- and post-operative factors. Am J Surg, 2018, 216(3): 511-517.
20.	蘭蓮君, 舒健, 唐光才, 等. 胰源性門靜脈高壓側支循環特征的64層螺旋CT表現. 中國醫學影像學雜志, 2017, 25(3): 227-230.
21.	Zhu K, Meng X, Pang P, et al. Gastric varices in patients with portal hypertension: evaluation with multidetector row CT. J Clin Gastroenterol, 2010, 44(5): e108-e115.
22.	陳光文, 劉曦嬌, 宋彬. 肝、胰源性門靜脈高壓側支循環開放情況的對比研究. 中國普外基礎與臨床雜志, 2018, 25(5): 622-628.
23.	Harris S, Nadkarni NA, Naina HV, et al. Splanchnic vein thrombosis in acute pancreatitis: a single-center experience. Pancreas, 2013, 42(8): 1251-1254.
24.	Weber SM, Rikkers LF. Splenic vein thrombosis and gastrointestinal bleeding in chronic pancreatitis. World J Surg, 2003, 27(11): 1271-1274.
25.	Pereira P, Peixoto A. Left-sided portal hypertension: a clinical challenge. GE Port J Gastroenterol, 2015, 22(6): 231-233.
26.	Joyce DL, Hong K, Fishman EK, et al. Multi-visceral resection of pancreatic VIPoma in a patient with sinistral portal hypertension. World J Surg Oncol, 2008, 6: 80.
27.	Ou HY, Huang TL, Chen TY, et al. Emergency splenic arterial embolization for massive variceal bleeding in liver recipient with left-sided portal hypertension. Liver Transpl, 2005, 11(9): 1136-1139.

1. 竇科峰, 于恒超. 胰源性門脈高壓癥. 肝膽外科雜志, 2009, 17(2): 83-84.
2. Heider TR, Azeem S, Galanko JA, et al. The natural history of pancreatitis-induced splenic vein thrombosis. Ann Surg, 2004, 239(6): 876-882.
3. 吳苾, 宋彬, 陳衛霞. 胰源性區域性門靜脈高壓的螺旋CT表現及臨床意義. 中國醫學影像技術, 2004, 20(9): 1461-1464.
4. Fernandes A, Almeida N, Ferreira AM, et al. Left-sided portal hypertension: a sinister entity. GE Port J Gastroenterol, 2015, 22(6): 234-239.
5. Butler JR, Eckert GJ, Zyromski NJ, et al. Natural history of pancreatitis-induced splenic vein thrombosis: a systematic review and meta-analysis of its incidence and rate of gastrointestinal bleeding. HPB (Oxford), 2011, 13(12): 839-845.
6. K?klü S, Coban S, Yüksel O, et al. Left-sided portal hypertension. Dig Dis Sci, 2007, 52(5): 1141-1149.
7. 張月寧, 錢家鳴, 陸星華, 等. 胰腺疾病相關性門脈高壓癥59例臨床分析. 中華消化雜志, 2006, 26(11): 721-725.
8. 趙欣, 雷澤華, 高峰畏, 等. 胰源性門靜脈高壓癥并上消化道出血的診治體會. 中國普外基礎與臨床雜志, 2019, 26(3): 348-350.
9. Adams DB, Mauterer DJ, Vujic IJ, et al. Preoperative control of splenic artery inflow in patients with splenic venous occlusion. South Med J, 1990, 83(9): 1021-1024.
10. Banks PA, Bollen TL, Dervenis C, et al. Classification of acute pancreatitis—2012: revision of the Atlanta classification and definitions by international consensus. Gut, 2013, 62(1): 102-111.
11. 中華醫學會外科學分會胰腺外科學組. 慢性胰腺炎診治指南(2014). 中華外科雜志, 2015, 53(4): 241-246.
12. 王錦萍, 崔毅, 王錦輝, 等. 上消化道出血15年臨床流行病學變化趨勢. 中華胃腸外科雜志, 2017, 20(4): 425-431.
13. Jia R, Li N, Xu BY, et al. Incidence, influencing factors, and prognostic impact of intraoperative massive blood loss in adolescents with neuromuscular scoliosis: A STROBE-compliant retrospective observational analysis. Medicine (Baltimore), 2017, 96(11): e6292.
14. 盧山, 陸慧敏, 張凌, 等. 胰腺假性囊腫致左側門靜脈高壓伴脾臟功能亢進的處理策略探討. 中國普外基礎與臨床雜志, 2018, 25(5): 553-558.
15. 廖刃, 劉進. 圍手術期血液管理: 由限制性輸血走向個體化輸血. 中華醫學雜志, 2014, 94(7): 481-482.
16. Nadler SB, Hidalgo JH, Bloch T. Prediction of blood volume in normal human adults. Surgery, 1962, 51(2): 224-232.
17. Gross JB. Estimating allowable blood loss: corrected for dilution. Anesthesiology, 1983, 58(3): 277-280.
18. Ejaz A, Spolverato G, Kim Y, et al. Variation in triggers and use of perioperative blood transfusion in major gastrointestinal surgery. Br J Surg, 2014, 101(11): 1424-1433.
19. Marchegiani G, Andrianello S, Pieretti-Vanmarcke R, et al. Hospital readmission after distal pancreatectomy is predicted by specific intra- and post-operative factors. Am J Surg, 2018, 216(3): 511-517.
20. 蘭蓮君, 舒健, 唐光才, 等. 胰源性門靜脈高壓側支循環特征的64層螺旋CT表現. 中國醫學影像學雜志, 2017, 25(3): 227-230.
21. Zhu K, Meng X, Pang P, et al. Gastric varices in patients with portal hypertension: evaluation with multidetector row CT. J Clin Gastroenterol, 2010, 44(5): e108-e115.
22. 陳光文, 劉曦嬌, 宋彬. 肝、胰源性門靜脈高壓側支循環開放情況的對比研究. 中國普外基礎與臨床雜志, 2018, 25(5): 622-628.
23. Harris S, Nadkarni NA, Naina HV, et al. Splanchnic vein thrombosis in acute pancreatitis: a single-center experience. Pancreas, 2013, 42(8): 1251-1254.
24. Weber SM, Rikkers LF. Splenic vein thrombosis and gastrointestinal bleeding in chronic pancreatitis. World J Surg, 2003, 27(11): 1271-1274.
25. Pereira P, Peixoto A. Left-sided portal hypertension: a clinical challenge. GE Port J Gastroenterol, 2015, 22(6): 231-233.
26. Joyce DL, Hong K, Fishman EK, et al. Multi-visceral resection of pancreatic VIPoma in a patient with sinistral portal hypertension. World J Surg Oncol, 2008, 6: 80.
27. Ou HY, Huang TL, Chen TY, et al. Emergency splenic arterial embolization for massive variceal bleeding in liver recipient with left-sided portal hypertension. Liver Transpl, 2005, 11(9): 1136-1139.

CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY

Risk factors for intraoperative massive hemorrhage in patients with pancreatitis-induced sinistral portal hypertension

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