Pseudoaneurysm of the splenic artery - an uncommon cause of delayed hemorrhage after pancreaticoduodenectomy

Hepatic artery protection using a polyglycolic acid sheet during pancreaticoduodenectomy: A multicenter study

BACKGROUND

Postpancreatectomy hemorrhage (PPH) is the most feared complication after pancreaticoduodenectomy (PD). The most common cause is erosion of the gastroduodenal artery stump. Preventive measures have been previously reported, but a consensus is lacking. The aim of this study was to analyze the preventive effect of reinforcing the hepatic artery using a polyglycolic acid (PGA) sheet during PD.

METHODS

A multicenter retrospective study was performed, collecting data from three tertiary hospitals in Korea. Patients receiving PD from January 2016 to December 2021 were included. The primary endpoint was rate of PPH from the hepatic artery. Arterial reinforcement (AR) was performed by wrapping the artery with Neoveil (Gunze Ltd) and applying fibrin glue. The perioperative data of patients who did not receive AR were compared with data of those who received AR.

RESULTS

A total of 904 patients were analyzed. The rate of PPH from the hepatic artery was significantly lower in the AR group. (3.5% vs 0.7%, p = .002) In patients with CR-POPF, the 90 day mortality rate of the AR group was less than half that of the non-AR group (7.2% vs 3.5%, p = .455) Risk factor analysis showed CR-POPF to be an independent risk factor for PPH. Arterial reinforcement was shown to be a strong protective factor for PPH (OR 0.20, 95% CI: 0.05-0.72, p = .014).

CONCLUSIONS

AR of the hepatic artery using Neoveil and fibrin glue is a simple method that greatly reduces the rate of PPH after PD.

Incidence and Contemporary Management of Delayed Bleeding Following Pancreaticoduodenectomy

BACKGROUND

Delayed bleeding after pancreaticoduodenectomy (PD) is a life-threatening complication. However, the optimal management remains unclear. We summarize our experience of the management of delayed bleeding after PD and define the outcomes associated with different types of management.

METHODS

All patients who underwent a PD between January 1987 and June 2020 at Johns Hopkins University were retrospectively reviewed. Delayed bleeding was defined as bleeding on or after postoperative day 5 following PD. Incidence, outcomes, and trends were reported.

RESULTS

Among the 6201 patients that underwent PD, delayed bleeding occurred in 130 (2.1%) at a median of 12 days (IQR: 9, 24) postoperation. The pattern of bleeding was classified as intraluminal (51.5%), extraluminal (40.8%), and mixed (7.7%). A clinically relevant postoperative pancreatic fistula and an intraabdominal abscess preceded the delayed bleeding in 43.1% and 31.5% of cases, respectively. Arterial pseudoaneurysm or bleeding from peripancreatic vessels was the most common reason (54.6%) with the gastroduodenal artery being the most common source (18.5%). Endoscopy, angiography, and reoperation were performed as a first-line approach in 35.4%, 52.3%, and 6.2% of patients, respectively. The overall mortality was 16.2% and decreased over the study period (p < 0.01).

CONCLUSIONS

Delayed bleeding following PD remains a life-threatening complication. The most common location of delayed bleeding is from the gastroduodenal artery. Angiography with embolization should be the initial approach for urgent bleeding with surgical re-exploration reserved for unstable patients or failed control of bleeding after interventional angiography or endoscopy.

Endovascular therapy choices for different sites of delayed postoperative arterial hemorrhage after hepatobiliary pancreatic surgery: a retrospective study

Background

Angiography and subsequent endovascular therapy is an effective technique for delayed postoperative arterial hemorrhage (PAH) after hepatobiliary pancreatic surgery. In this research, we aimed to evaluate endovascular therapy choices for different sites of delayed PAH after hepatobiliary pancreatic surgery.

Methods

A total of 85 patients with delayed PAH who underwent endovascular therapy at the Department of Radioactive Intervention of Eastern Hepatobiliary Surgery Hospital were retrospectively enrolled. According to the hemorrhage site, participants were divided into 3 groups, all of whom then received embolization, covered stent placement, or a combination of both. Ongoing or recurrent hemorrhages, intervention times, complications associated with intervention, and mortality rate were documented. The chi-squared (χ²) test was used for statistical analysis.

Results

A total of 22 participants with arterial branch hemorrhage underwent superselective embolization. Overall, 81.8% (18/22) of patients underwent embolization once. The successful hemostasis rate was 77.3% (17/22), and the mortality rate was 13.6% (3/22). A total of 53 participants with arterial trunk hemorrhage underwent embolization or covered stent placement. The rate of multi-time intervention, failure to achieve hemostasis, complications associated with intervention, and mortality was lower in the stent group than in the embolization group, and there was a significant difference in complications between the 2 groups (χ²=4.93, P=0.026). Among a total of 10 patients with multisite hemorrhage who underwent embolization, covered stent placement, or a combination, the successful hemostasis rate was 20%; and the mortality rate was 70%.

Conclusions

Superselective embolization is a safe treatment method for arterial branch hemorrhage, and covered stent placement may be a better choice for arterial trunk hemorrhage. Verification of these findings is required via additional large population studies.

Application of interventional embolization in the treatment of iatrogenic pseudoaneurysms

The present study aimed to investigate the clinical effectiveness and safety of endovascular embolization for the treatment of pseudoaneurysm secondary to previous abdominal and pelvic surgery or radiological percutaneous abdominal procedure. A retrospective review was performed on all patients with abdominal and pelvic pseudoaneurysm confirmed by CT angiography or digital subtraction angiography and treated with endovascular embolization. Different techniques of embolization with coils were applied and the outcomes, including clinical effectiveness and safety, were assessed. A total of 31 patients with a total of 32 pseudoaneurysms were included in the present study. Of these pseudoaneurysms, 23 were from the main trunks and branches of the gastroduodenal artery, 5 were from the splenic artery, 2 were from the common hepatic artery, 1 was from the right hepatic artery and 1 was from the right internal iliac artery. There were no serious complications observed and there was no occurrence of re-bleeding following embolization. The embolization of the pseudoaneurysms was successful in all patients. In conclusion, endovascular embolization is a safe and effective method for the treatment of secondary iatrogenic pseudoaneurysm in the abdomen and pelvis.

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.

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.

Rare postoperative hemorrhage after robotic-assisted pancreatoduodenectomy for pancreatic head cancer: a case report

Post-pancreaticoduodenectomy hemorrhage is a life-threatening complication that occurs in 2-10% of patients. The most common location for post-pancreaticoduodenectomy hemorrhage is the gastroduodenal artery stump. Nonetheless, unusual sources of hemorrhage, which are hard to locate, exist. Here, we report a rare postoperative hemorrhage after robotic-assisted pancreatoduodenectomy for pancreatic head cancer. A 67-year-old man presenting with appetite loss, general fatigue and painless jaundice was admitted to our ward. The patient had an elevated level of carbohydrate antigen 19-9 (50 U/mL). Computed tomography scan revealed a 17-mm wide low-density area in the uncinate process of the pancreas. Magnetic resonance cholangiopancreatography showed the dilation of bile and pancreatic ducts. Robotic-assisted pancreaticoduodenectomy was performed on the patient by using the da Vinci Model S Surgical System. On postoperative days 5 and 6, the patient vomited blood, and bloody fluid was observed in the drainage. Emergent gastroscopic examination was performed and revealed a large amount of hematocele in the stomach. On postoperative day 6, emergency operation was undertaken, and the output jejunal loop was found to have intussuscepted in the stomach. This is the first case report of output jejunal loop intussusception in the stomach that consequently caused hemorrhage after robotic-assisted pancreaticoduodenectomy for pancreatic head cancer.

Rare, Uncommon, and Unusual Complications After Pancreaticoduodenal Resection

Complications after pancreaticoduodenal resection occur in at least 30% of patients. Most are a direct result of an intraoperative event, dissection, or anastomoses which account for the most serious morbidities, sepsis, pseudoaneurysms, and hemorrhage. Rarely, complications are due to the systemic impact of the procedure even if the procedure itself was unremarkable. Rare systemic complications after PDR (Transfusion transmitted Babesiosis, pituitary apoplexy, and TRALI) and a number of uncommon and unusual other complications are discussed. Pancreaticoduodenal resection is a significant operation with serious consequences. Decisions on selection of candidates and safe operations should be thoughtful and always in surgeons' minds.