超选择性直肠上动脉栓塞术在直肠出血中的应用
作者:
作者单位:

1.滨州医学院附属医院,消化内科,山东 滨州 256603;2.滨州医学院附属医院,介入血管外科,山东 滨州 256603

作者简介:

王雪敏,滨州医学院附属医院主治医师,主要从事消化系统疾病方面的研究。

通信作者:

韩新强,Email: hxq_0543@163.com

基金项目:

滨州医学院科技计划基金资助项目(BY2019KJ13)。


Application of super-selective superior rectal artery embolization in rectal hemorrhage
Author:
Affiliation:

1.Department of Gastroenterology, Binzhou Medical University Hospital, Binzhou, Shandong 256603, China;2.Department of Interventional Medicine and Vascular Surgery, Binzhou Medical University Hospital, Binzhou, Shandong 256603, China

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    摘要:

    背景与目的 内痔是引起直肠出血的常见原因,当出血严重影响患者生活质量或危及生命时,由于存在手术禁忌无法进行外科手术或患者不愿接受外科手术,通过导管超选择性直肠上动脉(SRA)造影可快速、准确地定位出血部位,并可同期予以栓塞,实现快速止血目的。相比于传统的外科手术止血,血管腔内介入止血具有微创、并发症少、术后恢复快等特点,但国内对于超选择SRA栓塞术在内痔导致的直肠出血中的临床应用报道较少,其止血效果及安全性还存在争论。本研究旨在评价超选择性SRA栓塞术治疗内痔为原因的直肠出血的安全性及有效性,并就该方法相关的技术要点及注意事项做一探讨,以期为临床提供参考。方法 回顾性分析滨州医学院附属医院2016年12月—2021年10月接受超选择性SRA栓塞治疗的直肠出血患者的临床资料,观察SRA栓塞术后3~7 d(初期止血率)及术后1~12个月的止血效果(临床成功率)、术后并发症。结果 共50例成功实施超选择性SRA栓塞治疗的直肠出血患者,按照纳入和排除标准,共有29例内痔出血患者进入最终研究,其中Ⅱ度内痔11例,Ⅲ度内痔18例;男17例,女12例;平均年龄(51.8±12.2)岁。所有患者介入术中均使用金属弹簧圈(直径2~3 mm)联合明胶海绵颗粒(直径350~560 μm)或PVA颗粒(直径300~500 μm)行栓塞治疗,技术成功率100%。27例患者术后3~7 d出血症状消失,初期止血率为82.8%(24/29),术后1个月临床成功率为86.2%(25/29)。3例患者在随访6个月时便血复发,术后6个月临床成功率为75.9%(22/29),其中2例行髂内动脉分支栓塞后症状消失,1例选择保守治疗。所有患者得到随访,随访时间(10.7±2.5)个月,1例患者因术后里急后重感明显,术后1周行肠镜检查可见直肠小片状浅表黏膜溃疡,予以保守治疗;2例患者出现穿刺部位血肿,保守治疗后血肿消失,其余患者无介入栓塞相关的感染、肠穿孔、大出血等严重并发症发生。结论 超选择性SRA栓塞在治疗以Ⅱ~Ⅲ度内痔为原因的直肠出血中是一种相对安全、低风险的手术方法,短期止血效果肯定,具有较好的临床应用价值,值得推荐使用。

    Abstract:

    Background and Aims Internal haemorrhoids are common causes of rectal bleeding. When haemorrhage severely impacts patients' quality of life or is even life-threatening, and surgery cannot be performed due to contraindications or the patients are unwilling to undergo the operation, superselective superior rectal artery (SRA) angiography and embolization are one of the best options for rapid haemostasis. Interventional endovascular haemostasis has the characteristics of minimally invasive, fast recovery, and fewer postoperative complications than traditional surgical procedures. However, there are few reports on the application of superselective SRA embolization in rectal bleeding caused by internal haemorrhoids in our country, and its haemostatic effect and safety are still controversial. This study was conducted to evaluate the safety and efficacy of transcatheter super-selective SRA embolization in the treatment of rectal haemorrhage and discuss the technical points and cautions that may influence clinical outcomes, and provide references for clinical practice.Methods The clinical data of all rectal bleeding patients who underwent super-selective SRA embolization at Binzhou Medical University Hospital between December 2016 and October 2021 were retrospectively analysed. The haemostatic effect and postoperative complications of 3-7 d (initial haemostatic rate) and 1-12 months (clinical success rate) after SRA embolization were observed and analysed.Results A total of 50 patients with rectal bleeding successfully underwent superselective SRA embolization, and only 29 patients were included in the final analysis according to the inclusion and exclusion criteria. Among them, 11 patients had grade Ⅱ internal haemorrhoids, and 18 had grade Ⅲ internal haemorrhoids; 17 patients were males, and 12 were females, with a mean age of (51.8±12.2) years. All patients underwent SRA embolization with metal coils (2-3 mm) combined with gelatine sponge particles (350-560 μm) or PVA particles (300-500 μm), and the technical success rate was 100%. Bleeding control or clinical success rate was achieved in 82.8% (24/29) of patients at day 3 to 7 and 86.2% (25/29) at one month postoperatively. Recurrent bleeding occurred in 3 patients (3/25) at 6 months follow-up, and the clinical success rate was 75.9% (22/29) at 6 months postoperatively; two of the three patients underwent internal iliac branches embolization and the symptoms dissipated, while one with conservative management. All patients were followed up for (10.7±2.5) months. In one patient who presented with obvious tenesmus, a colonoscopy revealed a small piece of superficial ulcer on the rectum in the first week after the operation, and conservative management was performed. Two patients had hematoma at the puncture site, which disappeared after conservative treatment. Other patients noted no severe complications, such as infection, intestinal perforation, or massive haemorrhage related to interventional embolization.Conclusion Super-selective SRA embolization is a relatively safe and low-risk surgical method in treating rectal bleeding caused by grade Ⅱ-Ⅲ internal haemorrhoids. It has positive short-term efficacy, especially in an emergency setting. This method has a satisfactory practical application and is worth being recommended.

    Fig.
    图1 介入术中造影图片 A:超选SRA造影可见内痔血供丰富、造影剂浓聚(红色箭头);B:超选择SRA栓塞后造影提示痔区血管消失(红色箭头)Fig.1 Angiography images A: Super-selective SRA arteriogram showing the rectal hypervascularization (red arrow); B: Arteriogram following embolization of SRA showing no visible vascularization of the haemorrhoidal plexus (red arrows)
    图2 肠镜提示直肠两处浅表黏膜溃疡Fig.2 Enteroscopy showeing shallow mucosal ulcerations
    图3 介入术中造影图片 A:超选左侧髂内动脉造影提示阴部内动脉分支供血痔区显影(红色箭头);B:栓塞后造影提示痔区血管消失(红色箭头)Fig.3 Angiography images A: Selective left internaliliac artery arteriogram showing the inferior haemorrhoidal originating from the internal pudendal artery (red arrow); B: Arteriogram following embolization showing no visible vascularization of the inferior haemorrhoidal plexus (red arrow)
    Fig.
    图1 介入术中造影图片 A:超选SRA造影可见内痔血供丰富、造影剂浓聚(红色箭头);B:超选择SRA栓塞后造影提示痔区血管消失(红色箭头)Fig.1 Angiography images A: Super-selective SRA arteriogram showing the rectal hypervascularization (red arrow); B: Arteriogram following embolization of SRA showing no visible vascularization of the haemorrhoidal plexus (red arrows)
    图2 肠镜提示直肠两处浅表黏膜溃疡Fig.2 Enteroscopy showeing shallow mucosal ulcerations
    图3 介入术中造影图片 A:超选左侧髂内动脉造影提示阴部内动脉分支供血痔区显影(红色箭头);B:栓塞后造影提示痔区血管消失(红色箭头)Fig.3 Angiography images A: Selective left internaliliac artery arteriogram showing the inferior haemorrhoidal originating from the internal pudendal artery (red arrow); B: Arteriogram following embolization showing no visible vascularization of the inferior haemorrhoidal plexus (red arrow)
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王雪敏,武建,高建伟,韩新强.超选择性直肠上动脉栓塞术在直肠出血中的应用[J].中国普通外科杂志,2022,31(10):1373-1380.
DOI:10.7659/j. issn.1005-6947.2022.10.013

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  • 收稿日期:2021-04-12
  • 最后修改日期:2022-04-07
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  • 在线发布日期: 2022-10-31