机器人肾切除术后胰漏并出血一例

Pancreatic Fistula and Hemorrhage after Robot-Assisted Nephrectomy: A Case Report

摘要: 目的：总结巨大左肾肿瘤机器人辅助肾切除术后发生胰漏、腹腔感染及迟发性出血的诊疗经验。方法：回顾分析1例左肾上极巨大肾细胞癌患者的临床资料、围手术期影像、病理结果、实验室及引流量变化，并结合相关文献讨论并发症识别和多学科处理策略。结果：患者男，69岁，术前CT和MR提示左肾上极巨大囊实性肿块，与胰尾界面欠清。2025年7月4日行机器人辅助左肾切除术，术中发现肿瘤与脾脏、胰体尾部及十二指肠降部紧密粘连，分离后出现胰体尾部及十二指肠损伤，予以修补并置管引流。术后患者出现高淀粉酶引流、腹腔感染、营养不良、静脉血栓和反复血性引流，经持续引流冲洗、抗感染、营养支持、下腔静脉滤器置入及脾动脉栓塞等治疗后病情逐步稳定。结论：巨大左肾上极肿瘤若与胰脾区界面不清，即使采用机器人手术仍需警惕胰腺及邻近脏器损伤。术后高淀粉酶引流合并血性引流应提示胰漏相关感染和血管侵蚀风险，早期识别、有效引流、及时介入止血和连续多学科管理有助于改善预后。

Abstract: Objective: To summarize our experience in the diagnosis and treatment of pancreatic fistula, intra-abdominal infection, and delayed hemorrhage following robot-assisted nephrectomy for a giant left renal tumor. Methods: We conducted a retrospective analysis of the clinical data, perioperative imaging, pathological findings, laboratory results, and changes in drainage output for a patient with giant renal cell carcinoma of the upper pole of the left kidney. We also discussed strategies for identifying complications and multidisciplinary management in light of relevant literature. Results: The patient was a 69-year-old man. Preoperative CT and MRI scans revealed a massive cystic-solid mass in the upper pole of the left kidney with an indistinct interface at the pancreatic tail. On July 4, 2025, the patient underwent robot-assisted left nephrectomy. Intraoperatively, the tumor was found to be tightly adherent to the spleen, the body and tail of the pancreas, and the descending duodenum. Following dissection, injuries to the body and tail of the pancreas and the descending duodenum were identified; these were repaired and drained with tubes. Postoperatively, the patient developed high amylase levels in the drainage fluid, intra-abdominal infection, malnutrition, venous thrombosis, and recurrent bloody drainage. His condition gradually stabilized following treatment with continuous drainage and irrigation, antimicrobial therapy, nutritional support, inferior vena cava filter placement, and splenic artery embolization. Conclusion: In cases of massive tumors of the left renal upper pole with indistinct boundaries at the interface with the pancreas and spleen, caution regarding injury to the pancreas and adjacent organs is warranted even when robotic surgery is performed. Postoperative drainage with elevated amylase levels combined with bloody drainage should raise suspicion of pancreatic fistula-related infection and the risk of vascular erosion. Early identification, effective drainage, timely interventional hemostasis, and continuous multidisciplinary management contribute to improved prognosis.