Endovascular management of delayed post-pancreatectomy haemorrhage

Retromesenteric omental flap as arterial coverage in pancreaticoduodenectomy: A novel technique to prevent postpancreatectomy hemorrhage

BACKGROUND

Clinically relevant postpancreatectomy hemorrhage occurs in 10% to 15% of patients after pancreaticoduodenectomy, mainly in association with clinically relevant postoperative pancreatic fistula. Prevention of postpancreatectomy hemorrhage by arterial coverage with a round ligament plasty or an omental flap is controversial. This study assessed the impact of arterial coverage with an original retromesenteric omental flap on postpancreatectomy hemorrhage after pancreaticoduodenectomy.

METHODS

This single-center retrospective study included 812 open pancreaticoduodenectomies (2012-2021) and compared 146 procedures with arterial coverage using retromesenteric omental flap to 666 pancreaticoduodenectomies without arterial coverage. The Fistula Risk Score was calculated. The primary endpoint was a 90-day clinically relevant postpancreatectomy hemorrhage rate according to the International Study Group of Pancreatic Surgery classification.

RESULTS

There were more patients with a Fistula Risk Score ≥7 in the arterial coverage-retromesenteric omental flap group: 18 (12%) versus 48 (7%) (P < .01). Clinically relevant postpancreatectomy hemorrhage was less frequent in the arterial coverage- retromesenteric omental flap group than in the no arterial coverage group: 5 (3%) versus 66 (10%), respectively (P = .01). Clinically relevant postoperative pancreatic fistula occurred in 28 (19%) patients in the arterial coverage- retromesenteric omental flap group compared with 165 (25%) in the no arterial coverage group (P = .001). There were fewer reoperations for postpancreatectomy hemorrhage or postoperative pancreatic fistula in the arterial coverage- retromesenteric omental flap group: 1 (0.7%) versus 32 (5%) in the no arterial coverage group (P = .023). In multivariate analysis, arterial coverage with retromesenteric omental flap was an independent protective factor of clinically relevant postpancreatectomy hemorrhage (odds ratio 0.33; 95% confidence interval [0.12-0.92], P = .034) whereas postoperative pancreatic fistula of any grade (odds ratio = 10.1; 95% confidence interval: 5.1-20.3, P < .001) was predictive of this complication.

CONCLUSION

Arterial coverage with retromesenteric omental flap can reduce rates of clinically relevant postpancreatectomy hemorrhage after pancreaticoduodenectomy. This easy and costless technique should be prospectively evaluated to confirm these results.

Targeted versus Empiric Embolization for Delayed Postpancreatectomy Hemorrhage: A Retrospective Study of 312 Patients

PURPOSE

To assess the safety and clinical effectiveness of empiric embolization (EE) compared with targeted embolization (TE) in the treatment of delayed postpancreatectomy hemorrhage (PPH).

MATERIALS AND METHODS

The data of patients with delayed PPH between January 2012 and August 2022 were analyzed retrospectively. In total, 312 consecutive patients (59.6 years ± 10.8; 239 men) were included. The group was stratified into 3 cohorts according to angiographic results and treatment strategies: TE group, EE group, and no embolization (NE) group. The χ2 or Fisher exact test was implemented for comparing the clinical success and 30-day mortality. The variables related to clinical failure and 30-day mortality were identified by univariable and multivariable analyses.

RESULTS

Clinical success of transcatheter arterial embolization was achieved in 70.0% (170/243) of patients who underwent embolization. There was no statistical difference in clinical success and 30-day mortality between the EE and TE groups. Multivariate analyses demonstrated that malignant disease (odds ratio [OR] = 5.76), Grade C pancreatic fistula (OR = 7.59), intra-abdominal infection (OR = 2.54), and concurrent extraluminal and intraluminal hemorrhage (OR = 2.52) were risk factors for clinical failure. Moreover, 33 patients (13.6%) died within 30 days after embolization. Advanced age (OR = 2.59) and intra-abdominal infection (OR = 5.55) were identified as risk factors for 30-day mortality.

CONCLUSIONS

EE is safe and as effective as TE in preventing rebleeding and mortality in patients with angiographically negative delayed PPH.

Marginal Ulcer Following Completion Pancreatectomy Complicated by Portal Vein Erosion

Marginal ulcers, defined as ulcers at the duodenojejunostomy or gastrojejunostomy, are a known late-onset complication of pancreaticoduodenectomy (PD) and total pancreatectomy (TP) with mean incidence ranging from 5.4% to 36% per the literature. These ulcers carry a risk of complications including hemorrhage or perforation which can result in significant mortality. Marginal ulcers from PD and TP causing portal vein erosion are extremely rare and given the high incidence of mortality, it is important to have a multimodal approach to the treatment with awareness that early operative management should be considered if other modalities fail. We discuss the case of a 57-year-old female with history of pancreatic tail intraductal papillary mucinous neoplasm (IPMN) status post distal pancreatectomy/splenectomy and subsequent completion pancreatectomy for pancreatic head IPMN who presented with acute gastrointestinal bleed. The patient was successfully managed operatively with primary repair of the marginal ulcer after multiple failed endoscopic attempts.

Modified Appleby procedure for locally advanced pancreatic carcinoma: A primer for the radiologist

Pancreatic ductal adenocarcinoma (PDAC) is the most prevalent pancreatic neoplasm accounting for more than 90% of pancreatic malignancies. Surgical resection with adequate lymphadenectomy remains the only available curative strategy for patients with PDAC. Despite improvements in both chemotherapy regimen and surgical care, body/neck PDAC still conveys a poor prognosis because of the vicinity of major vascular structures, including celiac trunk, which favors insidious disease spread at the time of diagnosis. Body/neck PDAC involving the celiac trunk is considered locally advanced PDAC in most guidelines and therefore not eligible for upfront resection. However, a more aggressive surgical approach (i.e., distal pancreatectomy with splenectomy and en-bloc celiac trunk resection [DP-CAR]) was recently proposed to offer hope for cure in selected patients with locally advanced body/neck PDAC responsive to induction therapy at the cost of higher morbidity. The so-called "modified Appleby procedure" is highly demanding and requires optimal preoperative staging as well as appropriate patient preparation for surgery (i.e., preoperative arterial embolization). Herein, we review current evidence regarding DP-CAR indications and outcomes as well as the critical role of diagnostic and interventional radiology in patient preparation before DP-CAR, and early identification and management of DP-CAR complications.

Emergent vessel embolization for major traumatic and non-traumatic hemorrhage: Indications, tools and outcomes

Endovascular embolization of bleeding vessels in trauma and non-trauma patients is frequently used and is an important tool for bleeding control. It is included in the EVTM (endovascular resuscitation and trauma management) concept and its use in patients with hemodynamic instability is increasing. When the correct embolization tool is chosen, a dedicated multidisciplinary team can rapidly and effectively achieve bleeding control. In this article, we will describe the current use and possibilities for embolization of major hemorrhage (traumatic and non-traumatic) and the published data supporting these techniques as part of the EVTM concept.

Management of postoperative pancreatic fistula after pancreaticoduodenectomy

A postoperative pancreatic fistula (POPF) is the main complication after cephalic pancreaticoduodenectomy (CPD). Unlike its prevention, the curative management of POPFs has long been poorly codified. This review seeks best practices for managing POPFs after CPD. The diagnosis of a POPF is based on two signs: (i) an amylase level in drained fluid more than 3 times the upper limit of the blood amylase level; and (ii) an abnormal clinical course. In the standardised definition of the International Study Group of Pancreatic Surgery, a purely biochemical fistula is no longer counted as a POPF and is treated by gradual withdrawal of the drain over at most 3 weeks. POPF risk can be scored using pre- and intraoperative clinical criteria, many of which are related to the quality of the pancreatic parenchyma and are common to several scoring systems. The prognostic value of these scores can be improved as early as Day 1 by amylase assays in blood and drained fluid. Recent literature, including in particular the Dutch randomised trial PORSCH, argues for early systematic detection of a POPF (periodic assays, CT-scan with injection indicated on standardised clinical and biological criteria plus an opinion from a pancreatic surgeon), for rapid minimally invasive treatment of collections (percutaneous drainage, antibiotic therapy indicated on standardised criteria) to forestall severe septic and/or haemorrhagic forms, and for the swift withdrawal of abdominal drains when the risk of a POPF is theoretically low and evolution is favourable. A haemorrhage occurring after Day 1 always requires CT angiography with arterial time and monitoring in intensive care. Minimally invasive treatment of a POPF (radiologically-guided percutaneous drainage or, more rarely, endoscopic drainage, arterial embolisation) should be preferred as first-line treatment. The addition of artificial nutrition (enteral via a nasogastric or nasojejunal tube, or parenteral) is most often useful. If minimally invasive treatment fails, then reintervention is indicated, preserving the remaining pancreas if possible, but the expected mortality is higher.

Interventional Radiological Management and Prevention of Complications after Pancreatic Surgery: Drainage, Embolization and Islet Auto-Transplantation

Pancreatic surgery still remains burdened by high levels of morbidity and mortality with a relevant incidence of complications, even in high volume centers. This review highlights the interventional radiological management of complications after pancreatic surgery. The current literature regarding the percutaneous drainage of fluid collections due to pancreatic fistulas, percutaneous transhepatic biliary drainage due to biliary leaks and transcatheter embolization (or stent–graft) due to arterial bleeding is analyzed. Moreover, also, percutaneous intra-portal islet auto-transplantation for the prevention of pancreatogenic diabetes in case of extended pancreatic resection is also examined. Moreover, a topic not usually treated in other similar reviewsas percutaneous intra-portal islet auto-transplantation for the prevention of pancreatogenic diabetes in case of extended pancreatic resection is also one of our areas of focus. In islet auto-transplantation, the patient is simultaneously donor and recipient. Differently from islet allo-transplantation, it does not require immunosuppression, has no risk of rejection and is usually efficient with a small number of transplanted islets.

Conversion to pancreaticogastrostomy for salvage of disrupted pancreaticojejunostomy following pancreaticoduodenectomy

Purpose

This study aimed to report on a pancreas-preserving strategy consisting of the conversion to pancreaticogastrostomy (PG) for the salvage of disrupted pancreaticojejunostomy (PJ) following pancreaticoduodenectomy (PD).

Methods

This single-center retrospective study included 188 patients who underwent PD between March 2000 and June 2021. Conversion to PG was performed by placing the pancreatic stump with an internal stent in the stomach through the posterior gastrostomy and suturing the wound in 2 layers through the anterior gastrostomy.

Results

A total of 181 patients underwent PJ, while 7 underwent PG. Of all patients, 6 had International Study Group on Pancreatic Fistula grade C postoperative pancreatic fistulae (POPF; 3.3%) and 23 had grade B POPF (12.7%). Two of the 6 grade C patients underwent completion pancreatectomy and died of liver failure after common hepatic artery embolization due to pseudoaneurysm. Conversion to PG was performed in 4, all of whom survived and experienced no long-term pancreatic fistulae, remnant pancreatic atrophy, or newly developed diabetes after a median follow-up period of 11.5 months.

Conclusion

Conversion to PG for the salvage of disrupted PJ following PD is safe and effective in selected patients that can lower mortality rates while maintaining pancreatic function.

Endovascular treatment for delayed post-pancreaticoduodenectomy hemorrhage of unusual origin (splenic artery branch)

Objective

The objective of this study was to investigate the method, efficacy, and safety of endovascular treatment (EVT) of delayed splenic artery branch (SAB) hemorrhage after pancreaticoduodenectomy.

Methods

From March 2019 to January 2022, all patients underwent EVT of SAB for delayed post-pancreaticoduodenectomy hemorrhage were included. Demographic, laboratory, angiographic, and clinical follow-up data were collected and analyzed.

Results

A total of eight patients were enrolled. In two patients, celiac axis angiography alone failed, but selective splenic artery (SA) angiography demonstrated the SAB bleeding; SAB erosions in four patients with recurrent bleeding were successfully detected by a second angiography; four patients underwent balloon catheter placement at the SA for temporary hemostasis and to further confirm the SAB bleeding before the subsequent EVT. Superselective embolization was performed in only one patient (12.5%; 1/8); covered stent implantation at the SA was performed in two patients (25%; 2/8); Embolization of the SA was performed in the remaining five patients (62.5%; 5/8). The technical success rate, clinical success rate, and in-hospital mortality were 100.0%, 87.5%, and 25%, respectively. No severe complications related to EVT occurred.

Conclusions

EVT of SAB for delayed post-pancreaticoduodenectomy hemorrhage is effective and safe. An awareness of the SAB as a potential bleeding source, together with appropriate endovascular procedures including selective SA angiography, repeat angiography, balloon catheter placement at the SA, and applicable hemostasis protocol, could achieve a high success rate of managing SAB hemorrhage.

Delayed Postoperative Hemorrhage Complicating Major Supramesocolic Surgery Management and Outcomes

BACKGROUND

The place of surgery and interventional radiology in the management of delayed (> 24 h) hemorrhage (DHR) complicating supramesocolic surgery is still to define. The aim of the study was to evaluate outcomes of DHR using a combined multimodal strategy.

METHODS

Between 2005 and 2019, 57 patients (median age 64 years) experienced 86 DHR episodes after pancreatic resection (n = 26), liver transplantation (n = 24) and other (n = 7). Hemodynamically stable patients underwent computed tomography evaluation followed by interventional radiology (IR) treatment (stenting and/or embolization) or surveillance. Hemodynamically unstable patients were offered upfront surgery. Failure to identify the leak was managed by either prophylactic stenting/embolization of the most likely bleeding source or surveillance.

RESULTS

Mortality was 32% (n = 18). Bleeding recurrence occurred in 22 patients (39%) and was multiple in 7 (12%). Sentinel bleeding was recorded in 77 (81%) of episodes, and the bleeding source could not be identified in 26 (30%). Failure to control bleeding was recorded in 9 (28%) of 32 episodes managed by surgery and 4 (11%) of 41 episodes managed by IR (p = 0.14). Recurrence was similar after stenting and embolization (n = 4/18, 22% vs n = 8/26, 31%, p = 0.75) of the bleeding source. Recurrence was significantly lower after prophylactic IR management than surveillance of an unidentified bleeding source (n = 2/10, 20% vs. n = 11/16, 69%, p = 0.042).

CONCLUSION

IR management should be favored for the treatment of DHR in hemodynamically stable patients. Prophylactic IR management of an unidentified leak decreases recurrence risks.

Endovascular Hepatic Artery Stents in the Modern Management of Postpancreatectomy Hemorrhage

Background

Postoperative hemorrhage is a potentially lethal complication of pancreatoduodenectomy. This study reports on the use of endovascular hepatic artery stents in the management of postpancreatectomy hemorrhage.

Methods

This is a retrospective analysis of a prospectively maintained, consecutive dataset of 440 patients undergoing pancreatoduodenectomy over 68 months. Data are presented on bleeding events and outcomes, and contextualized by the clinical course of the denominator population. International Study Group of Pancreatic Surgery terminology was used to define postpancreatectomy hemorrhage.

Results

Sixty-seven (15%) had postoperative hemorrhage. Fifty (75%) were male and this gender difference was significant (P = 0.001; 2 proportions test). Postoperative pancreatic fistulas were more frequent in the postoperative hemorrhage group (P = 0.029; 2 proportions test). The median (interquartile range [IQR]) delay between surgery and postoperative hemorrhage was 5 days (2-14 days). Twenty-six (39%) required intervention comprising reoperation alone in 12, embolization alone in 5, and endovascular hepatic artery stent deployment in 5. Four further patients underwent more than 1 intervention with 2 of these having stents. Endovascular stent placement achieved initial hemostasis in 5 of 7 (72%). Follow-up was for a median (IQR) of 199 days (145-400 days) poststent placement. In 2 patients, the stent remained patent at last follow-up. The remaining 5 stents occluded with a median (IQR) period of proven patency of 10 days (8-22 days).

Conclusions

This study shows that in the specific setting of postpancreatoduodenectomy hemorrhage with either a short remnant gastroduodenal artery bleed or a direct bleed from the hepatic artery, where embolization risks occlusion with compromise of liver arterial inflow, endovascular hepatic artery stent is an important hemostatic option but is associated with a high risk of subsequent graft occlusion.

Empiric Transcatheter Embolization for Acute Arterial Upper Gastrointestinal Bleeding: A Meta-Analysis

OBJECTIVE. The purpose of this study was to conduct a meta-analysis to assess the safety and efficacy of empiric embolization compared with targeted embolization in the treatment of acute upper gastrointestinal bleeding (UGIB). MATERIALS AND METHODS. We searched the PubMed and Cochrane Library databases for studies performed without language restrictions from January 2000 to November 2019. Only clinical studies with a sample size of five or more were included. Clinical success, rebleeding and complication rates, survival rates, bleeding cause, embolic materials, and vessels embolized were recorded. Empiric embolization and targeted embolization (i.e., embolization performed based on angiographic evidence of ongoing bleeding) were compared when possible. Meta-analysis was performed. RESULTS. Among 13 included studies (12 retrospective and 1 prospective), a total of 357 of 725 patients (49.2%) underwent empiric embolization for UGIB. The clinical success rate of empiric embolization was 74.7% (95% CI, 63.1-86.3%) among the 13 studies, and the survival rate was 80.9% (95% CI, 73.8-88.0%) for 10 studies. On the basis of comparative studies, no statistically significant difference was observed between empiric and targeted embolization in terms of rebleeding rate in 111 studies (36.5% vs 29.6%; odds ratio [OR], 1.13; 95% CI, 0.77-1.65; p = .53), mortality in eight studies (23.3% vs 18.0%; OR, 1.44; 95% CI, 0.89-2.33; p = .14), and need for surgery to control rebleeding in four studies (17.8% vs 13.4%; OR, 1.34; 95% CI, 0.58-3.07; p = .49). The pooled embolization-specific complications were 1.9% (empiric) and 2.4% (targeted). CONCLUSION. According to all available published evidence, empiric embolization assessed with endoscopic or preprocedural imaging findings (or both) appears to be as effective as targeted embolization in preventing rebleeding and mortality in patients with angiographically negative acute UGIB. Because of its favorable safety profile, empiric embolization should be considered for patients in this clinical scenario.

Postpancreatectomy hemorrhage with negative angiographic findings: outcomes of empiric embolization compared to conservative management

OBJECTIVE

To evaluate the efficacy of empiric embolization for postpancreatectomy hemorrhage (PPH) with negative angiographic signs of active bleeding.

MATERIALS AND METHODS

A total of 100 patients (76 men, 24 women) who were diagnosed with PPH with angiographic findings revealing no signs of active bleeding from December 2013 to December 2019 were included in the study. The patients were divided into two groups according to whether the procedures were performed with or without empiric embolization in angiography (group of empiric embolization, N=47; group of no embolization, N=53). Data reflecting patients' characteristics, hemorrhagic details, classification of PPH grade, and postoperative complications were acquired. The rates of clinical success in hemostasis and mortality were compared between the group of empiric embolization and the group of no embolization.

RESULTS

In the group of empiric embolization, the rate of clinical success in hemostasis and mortality were 61.7% and 27.7%, respectively. In the group of no embolization, the rates of clinical success in hemostasis and mortality were 39.6% and 13.2%, respectively. The rate of clinical success in hemostasis in the group of empiric embolization was significantly higher than that in the group of no embolization (p = 0.028). There was no statistically significant difference in mortality between the different groups (p = 0.071).

CONCLUSION

The clinical success rate of hemostasis in patients with empiric embolization is higher than that in patients with no embolization. Empiric embolization may be an efficacious hemostatic treatment for PPH with angiographic findings revealing no signs of active bleeding.

Outcome of interventional radiology for delayed postoperative hemorrhage in hepatobiliary and pancreatic surgery

BACKGROUND AND AIM

Postoperative hemorrhage is a rare but potentially lethal complication of hepatobiliary and pancreatic surgeries. This study aimed to retrospectively evaluate the clinical outcome of patients with delayed postoperative hemorrhage and compare the results according to the surgical procedure.

METHODS

Overall, 4220 patients underwent surgery for hepatobiliary and pancreatic diseases. Delayed postoperative hemorrhage (observed more than 24 h postoperatively) occurred in 62 patients. Of these, 61 underwent interventional radiology to achieve hemostasis. Patients' clinical data were analyzed retrospectively. The chi-squared or Fisher's exact test was used in data analysis.

RESULTS

A total of 62 patients (1.5%) developed delayed postoperative hemorrhage; 61 (1.4%) of them underwent interventional radiology to achieve hemostasis. Median duration from surgery to interventional radiology was 19 days (range: 5-252 days). Sentinel bleeding was detected in 31 patients; Clinical success was achieved in 54 patients (88.5%) by interventional radiology. Overall mortality rate was 26.2%. Causes of 16 in-hospital deaths were uncontrollable hemorrhage (n = 4) and worsening of general condition after hemostasis (n = 12). Mortality rates were 50.0% (11/22) and 12.8% (5/39) after hepatobiliary surgery and pancreatic resection, respectively. Mortality rate was significantly higher after hepatobiliary surgery than after pancreatic surgery (P = 0.002).

CONCLUSIONS

Interventional radiology can be successfully performed to achieve hemostasis for delayed hemorrhage after hepatobiliary and pancreatic surgeries. Because successful interventional radiology does not necessarily lead to survival, particularly after hepatobiliary surgery, meticulous attention to prevent surgical complications and intensive treatments before and after interventional radiology are required to improve outcomes.

Clinical efficacy of coil embolization in treating pseudoaneurysm post-Whipple operation

The present study aimed to evaluate the clinical efficacy and safety of angiography and coil embolization for pseudoaneurysm post-pancreatoduodenectomy (PD). A total of 17 patients with gastrointestinal or abdominal hemorrhage after PD were included in the present study. Angiography was performed on the celiac artery, common hepatic artery, splenic artery, gastroduodenal artery and superior mesenteric artery to determine the size of the pseudoaneurysm, the parent artery and its collateral branches. A variety of embolization techniques have been applied to embolize pseudoaneurysm, including the sac packing technique, proximal embolization, exclusion technique and sandwich technique. Different techniques with coils were used for embolization and the clinical effects of embolization were analyzed. A total of 18 pseudoaneurysms were identified in 17 patients. In 2 patients, severe technical complications occurred, including migration of the coil and rupture of pseudoaneurysm, and one of them died, which may have been associated with this complication. No serious clinical complications were observed in the other patients. A total of 7 patients had mild clinical complications, including mild abdominal and dorsal pain, which were alleviated after symptomatic management. A total of 15 patients with definite pseudoaneurysm were successfully embolized without re-bleeding and complications. The clinical success rate was 94.1% (16/17). In conclusion, a variety of embolization techniques may be applied for the treatment of pseudoaneurysm after PD, which have high technical and clinical success rates and small trauma. It is recommended in emergency situations, but care should be taken to avoid serious technical complications.

Postpancreatoduodenectomy Hemorrhage: Association between the Causes and the Severity of the Bleeding

Introduction

Of the complications following pancreatoduodenectomy (PD), postpancreatoduodenectomy hemorrhage (PPH) is the least common, but severe forms can be life-threatening without urgent treatment. While early PPH is mostly related to surgical hemostasis, late PPH is more likely due to complex physiopathological pathways secondary to different etiologies. The understanding of such etiologies could therefore be of great interest to help guide the treatment of severe, potentially life-threatening, late PPH cases.

Objective

The aim of this retrospective study was to assess the causes of PPH as a complication and explore a possible association between the causes and the severity of late PPH.

Methods

A retrospective study was performed at the HPB and Surgical Oncology Unit, Rambam Health Care Campus, Haifa, Israel. The charts of all patients submitted for PD were reviewed, and all patients with PPH were included. The timing, cause, and severity of PPH as well as other information were collected. A statistical analysis on the possible association between cause and severity of late PPH was performed.

Results

A total of 347 patients underwent PD, 18 of whom (5.18%) developed PPH. Early PPH was reported in 1 patient (5.6%) with severe bleeding from the gastric staple line. Late PPH was reported in 17 patients (94.4%). The most common causes of late PPH were bleeding from a vascular pseudoaneurysm (PSA) reported in 6 patients, 1 with mild and 5 with severe hemorrhage, and bleeding from a gastroenteric anastomosis marginal ulcer reported in 6 patients, all with mild hemorrhage. No etiology was found in 5 patients with mild hemorrhage. A significant association was found between the severity of late hemorrhage and vascular PSA as the cause of the bleeding (p = 0.001). All PSA bleeding occurred in cases complicated by a postoperative pancreatic fistula (POPF), with a significant statistical association (p < 0.001).

Conclusions

The most common cause of PPH was bleeding from a vascular PSA; the majority of these cases involved severe bleeding with late presentation, and all were associated with a POPF formation. In such cases, early detection by computed tomography angiography is mandatory, thereby promoting urgent treatment by angiography of vascular bleeding complications following PD.

Prolonged operating time is a significant perioperative risk factor for arterial pseudoaneurysm formation and patient death following hemorrhage after pancreaticoduodenectomy

BACKGROUND

Arterial pseudoaneurysm is a rare but potentially fatal complication after pancreaticoduodenectomy (PD). This study aimed to evaluate the incidence and predictors associated with pseudoaneurysm formation and patient death caused by its rupture.

PATIENTS AND METHOD

We retrospectively reviewed the data of 453 patients who underwent PD from April 2007 to February 2019. Uni- and multivariate analysis and receiver operating characteristic (ROC) curve analysis were performed to identify risk factors and optimal cutoff values.

RESULTS

Among the 453 patients, 22 (4.9%) developed pseudoaneurysm after PD. Median duration from surgery to detection of pseudoaneurysm was 17.0 (1-51) days. The locations of pseudoaneurysms were hepatic artery in 8, splenic artery in 3, gastroduodenal artery in 4, gastric artery in 2 and others in 5 patients, and 72.7% (16/22) of patients presented with hemorrhage. All pseudoaneurysms were treated using angioembolization. Lower age (<65.5 years, p = 0.004), prolonged operation time (Cutoff ˃610 min, p = 0.026) and postoperative pancreatic fistula (POPF) (p = 0.013) were the independent risk factors for development of pseudoaneurysm. 6 (27.3%) patients died due to rupture of pseudoaneurysm and prolonged operation time (Cutoff ˃657 min, p = 0.043) was a significant risk factor for death related to pseudoaneurysm.

CONCLUSION

Prolonged operating time was identified as a risk factor for both pseudoaneurysm formation and patient death following pseudoaneurysm bleeding. Interventional radiology treatment offered a central role in the treatment of pseudoaneurysms after PD. Therefore, it is important to have a high index of suspicion in high risk patients of the possibility of pseudoaneurysm formation and bleeding.

Clinical features and outcomes of endovascular treatment of latent pseudoaneurysmal bleeding after pancreaticoduodenectomy

BACKGROUND

The endovascular treatment is the first-line therapy for late massive arterial haemorrhage after pancreaticoduodenectomy (PD). This study aimed to evaluate the clinical features and outcomes of patients who experienced pseudoaneurysm (PA) bleeding after PD and treated with transcatheter arterial embolization (TAE) and stent-graft placement (SGP).

METHODS

A total of 37 patients (TAE = 16, stent graft = 16, both = 5) had an endovascular treatment due to hepatic artery PA bleeding after PD at our institution from January 2008 to December 2018.

RESULTS

There were 35 men and two women with a mean age of 62 years (range 45-82 years). The latency of bleeding ranged from postoperative days 3 to 46 (median day 21). The most common site of bleeding was gastroduodenal artery stump (n = 22). In TAE group (n = 16), the technical success rate was 100% and the clinical success rate was 87.5%. In SGP group (n = 16), the technical and clinical success rates were 100% and 93.8%. Five patients underwent SGP and TAE simultaneously; TAE was performed to prevent endoleak. A total of three patients experienced hepatic ischaemia (TAE = 2, SGP = 1). However, there was no statistically significant difference of hepatic ischaemia occurrence between the two groups P = 0.55).

CONCLUSIONS

In patients with suspected PA, urgent angiography should be considered immediately for diagnosis and treatment. The SGP can be performed first if it is technically feasible. However, TAE is also a safe and effective treatment in patients with intact portal flow, as well as those with preserved collateral pathways after hepatobiliary surgery.

Diagnosis and management of postpancreatectomy hemorrhage: a systematic review and meta-analysis

BACKGROUND

Postpancreatectomy hemorrhage is a potentially lethal complication after pancreatic resection. The objective of this systematic review is to provide insight in the current status of incidence, detection, management and clinical outcomes of late postpancreatectomy hemorrhage.

METHODS

A systematic search was conducted on the literature from February 2007 to July 2018 in PubMed, Embase and the Cochrane library. Included were clinical studies with clinical outcomes on late postpancreatectomy hemorrhage defined according to the International Study Group of Pancreatic Surgery definition (i.e. occurring >24 h after pancreatic resection).

RESULTS

A total of 14 studies on 467 patients with late postpancreatectomy hemorrhage were included. The incidence of late postpancreatectomy hemorrhage ranged from 3% to 16% (weighted mean: 5%). Seventy-four patients received conservative treatment; 252 patients underwent primary endovascular intervention; 82 patients underwent primary relaparotomy; 56 patients underwent primary endoscopic intervention; and three patients died before any intervention could be performed. CT-scan and diagnostic angiography were able to identify the source of hemorrhage in 67% (66/98) and 69% (114/166) of patients, respectively. The most frequent origin of the hemorrhage was the gastroduodenal artery stump (79/275; 29%), followed by the common hepatic artery (51/275; 19%) and splenic artery (32/275; 12%). Overall mortality was 21% (98/464 patients; range 0%-38%). Mortality was lower after primary interventional angiography as compared to primary relaparotomy (16% vs 37% respectively).

CONCLUSIONS

This systematic review provides a comprehensive overview of the current literature for severe late postpancreatectomy hemorrhages. CT-scan and diagnostic angiography are equally sensitive in detecting the bleeding source. Interventional angiography appears to be associated to lower mortality as compared to relaparotomy and endoscopy as first intervention for postpancreatectomy hemorrhage.

Strategy and management of severe hemorrhage complicating pancreatitis and post-pancreatectomy

PURPOSE

Transcatheter arterial embolization (TAE) is increasingly used as the first-line treatment for hemorrhage complicating pancreatitis and post-pancreatectomy. However, the optimal therapeutic strategy remains unclear.

METHODS

Among 1924 consecutive patients, 40 patients with severe pancreatic hemorrhage in Xuanwu Hospital were enrolled between 2005 and 2017. Patients underwent angiography and direct TAE for primary diagnosis and treatment of bleeding. Repeat TAE, watch and wait, and laparotomy were used as the other therapeutic options. Patient data, technical success, and 90-day survival were identified.

RESULTS

Pancreatic diseases underlying hemorrhage included acute pancreatitis (n=19, 47.5%), chronic pancreatitis (n=12, 30%), and pancreatic cancer (n=9, 22.5%). A history of percutaneous catheter drainage or pancreatic surgery was seen in 29 patients (72.5%). There were 48 angiographies, 31 embolizations, and 5 laparotomies performed. Rebleeding occurred in 8 patients (20%); 4 of whom underwent re-embolization, 3 had laparotomy, and 1 had conservative treatment. Successful clinical hemostasis was achieved in 37 patients. Complications were observed in only 2 patients with renal failure and 1 patient with hepatic insufficiency. In total, 25 patients (62.5%) were alive at the 90-day follow-up.

CONCLUSION

Endovascular management is effective for achieving hemostasis in severe pancreatic hemorrhage with a high success rate and low recurrence, and laparotomy is not suitable for rebleeding cases.