Hemorrhage after Major Pancreatic Resection: Incidence, Risk Factors, Management, and Outcome

Surgical outcomes of locally advanced gastrointestinal stromal tumors after multivisceral resection: A retrospective study of 64 patients at a single institution

To analyze the outcome in patients who have undergone multivisceral resection (MVR) for locally advanced gastrointestinal stromal tumors (GISTs), and identify the risk factors for tumor recurrence and postoperative morbidity. Sixty-four patients who operated for locally advanced GISTs with MVR in PPeking University Cancer Hospital Sarcoma Center (PUCHSC) between 2013 and 2021 were identified. Clinicopathologic characteristics, surgical outcomes, recurrence, and 5-year recurrence-free and overall survival were evaluated. The mean age of the patients was 60 years. Mean tumor size was 11.1 cm. Complete resection was achieved in all patients. The estimated 5-year recurrence-free and overall survival were 86.6% and 90.0%, respectively. Independent factor of recurrence following surgery was mitotic count on multivariate analysis. Overall postoperative morbidity was 53.1% (n = 34). Severe morbidity was 21.9% (n = 14). The most common severe complication was clinically relevant pancreatic fistula (n = 12, 18.8%), followed by anastomotic leakage (n = 4, 6.3%) and Intraabdominal abscess (n = 4, 6.3%). Multivariate analysis showed that preoperative imatinib therapy could reduce overall morbidity. Long operation time, combined colectomy and pancreatectomy were independent risk factors for postoperative severe morbidity. Compared to partial pancreatectomy, pancreaticoduodenectomy (PD) was significantly increased the incidence of severe morbidity. In conclusion, compared to systemic therapy alone, the outcome of locally advanced GISTs after MVR was more favorable. Despite the high overall morbidity, the postoperative severe morbidity and mortality of MVR were acceptable. Preoperative imatinib therapy should be recommended whenever possible. Combined pancreatectomy and colectomy are associated with significant postoperative severe morbidities. PD should be thoroughly discussed and be subject to MDT approach before surgery.

Imaging after Pancreatic Surgery: Expected Findings and Postoperative Complications

Pancreatic surgery is considered one of the most technically challenging surgical procedures, despite the evolution of modern techniques. Neoplasms remain the most common indication for pancreatic surgery, although inflammatory conditions may also prompt surgical evaluation. The choice of surgical procedure depends on the type and location of the pathologic finding because different parts of the pancreas have separate vascular supplies that may be shared by adjacent organs. The surgical approach could be conventional or minimally invasive (laparoscopic, endoscopic, or robotic assisted). Because of the anatomic complexity of the pancreatic bed, perioperative complications may be frequently encountered and commonly involve the pancreatic-biliary, vascular, lymphatic, or bowel systems, irrespective of the surgical technique used. Imaging plays an important role in the assessment of suspected postoperative complications, with CT considered the primary imaging modality, while MRI, digital subtraction angiography, and molecular imaging are considered ancillary diagnostic tools. Accurate diagnosis of postoperative complications requires a solid understanding of pancreatic anatomy, surgical indications, normal postoperative appearance, and expected postsurgical changes. The practicing radiologist should be familiar with the most common perioperative complications, such as anastomotic leak, abscess, and hemorrhage, and be able to differentiate these entities from normal anticipated postoperative changes such as seroma, edema and fat stranding at the surgical site, and perivascular soft-tissue thickening. In addition to evaluation of the primary operative fossa, imaging plays a fundamental role in assessment of the adjacent organ systems secondarily affected after pancreatic surgery, such as vascular, biliary, and enteric complications. Published under a CC BY 4.0 license. Test Your Knowledge questions are available in the supplemental material. See the invited commentary by Winslow in this issue.

Endovascular treatment of postoperative hemorrhage after pancreatectomy: a retrospective study

BACKGROUND

Ruptured aneurysm is a serious complication of distal pancreatectomy (DP) or pancreatoduodenectomy (PD) that can be life-threatening if not treated promptly. This study aimed to examine the efficacy of a Viabahn stent graft for stopping bleeding after pancreatectomy.

METHODS

Between April 2016 and June 2022, we performed 245 pancreatectomies in our institution. Six patients experienced postoperative bleeding and underwent endovascular treatment.

RESULTS

All six cases of bleeding occurred post-PD (3.7%). The bleeding was from gastroduodenal artery (GDA) pseudoaneurysms in three patients, and Viabahn stent grafts were inserted. All three patients did not show liver function abnormalities or hepatic blood flow disorders. One patient with a Viabahn stent graft experienced rebleeding, which required further management to obtain hemostasis. Of the six cases in which there was hemorrhage, one case of bleeding from the native hepatic artery could not be managed.

CONCLUSIONS

Using the Viabahn stent graft is an effective treatment option for postoperative bleeding from GDA pseudoaneurysms following PD. In most cases, using this device resulted in successful hemostasis, without observed abnormalities in hepatic function or blood flow.

Pancreatic surgery in elderly patients: results of 329 consecutive patients during 10 years

Introduction

There is a progressive shift from a younger population to an older population throughout the world. With the population age shift, surgeons will be more encountered with older patient profiles. We aim to determine age-related risk factors of pancreatic cancer surgery and the effect of patient age on outcomes after pancreatic surgery.

Materials and methods

A retrospective review was conducted with data obtained from consecutive 329 patients whose pancreatic surgery was performed by a single senior surgeon between January 2011 and December 2020. Patients were divided into three groups based on age: patients younger than 65 years old, between 65 and 74 years old, and older than 74 years old. Demographics and postoperative outcomes of the patients were evaluated and compared between these age groups.

Results

The distribution of a total of 329 patients into the groups was 168 patients (51.06%) in Group 1 (age <65 years old), 93 patients (28.26%) in Group 2 (age ≥65 and <75 years old), and 68 patients (20.66%) in Group 3 (age ≥75 years old). The overall postoperative complications were statistically significantly higher in Group 3 than in Group 1 and Group 2 (p = 0.013). The comprehensive complication index of the patients in each group was 23.1 ± 6.8, 20.4 ± 8.1, and 20.5 + 6.9, respectively (p = 0.33). Fisher's exact test indicated a significant difference in morbidity in patients with ASA 3-4 (p = 0.023). In-hospital or 90-day mortality was observed in two patients (0.62%), one from Group 2 and one from Group 3. The 3-year survival rates for each group were 65.4%, 58.8%, and 56.8%, respectively (p = 0.038).

Conclusion

Our data demonstrate that comorbidity, ASA score, and the possibility of achieving a curative resection do have significantly more impact than age alone.

The falciform/round ligament "flooring," an effective method to reduce life-threatening post-pancreatectomy hemorrhage occurrence

PURPOSE

Late post-pancreatectomy hemorrhage (PPH) represents the most severe complication after pancreatic surgery. We have measured the efficacy of major vessels "flooring" with falciform/round ligament to prevent life-threatening grade C late PPH after pancreaticoduodenectomy (PD) and distal pancreatectomy (DP).

METHODS

All consecutive patients who underwent PD and DP between 2013 and 2021 were retrospectively reviewed on a prospectively maintained database. The cohort was divided in two groups: "flooring" vs. "no flooring" method group. The "no flooring" group had omental flap interposition. Patient characteristics and operative and postoperative data including clinically relevant postoperative pancreatic fistula (CR-POPF), late PPH (grade B and C), and 90-day mortality were compared between the two groups.

RESULTS

Two hundred and forty patients underwent pancreatic resections, including 143 PD and 97 DP. The "flooring" method was performed in 61 patients (39 PD and 22 DP). No difference was found between the two groups concerning severe morbidity, CR-POPF, delayed PPH, and mortality rate. The rate of patients requiring postoperative intensive care unit was lower in the "flooring" than in the "no flooring" method group (11.5% vs. 25.1%, p = 0.030). Among patients with grade B/C late PPH (n = 30), the rate of life-threatening grade C late PPH was lower in the "flooring" than in the "no flooring" method group (28.6% (n = 2/7) vs. 82.6% (n = 19/24), p = 0.014). Risk factor analysis showed that the "flooring" method was the only protective factor against grade C late PPH occurrence (p = 0.013).

CONCLUSION

The "flooring" method using the falciform/round ligament should be considered during pancreatectomies to reduce the occurrence of life-threatening grade C late PPH.

Influence of Hemorrhagic Complications of Pancreatoduodenectomy in Patients with Cancer on Short- and Long-Term Mortality

BACKGROUND

With a mortality rate of up to 30%, post-pancreatectomy hemorrhage (PPH) remains a serious complication after pancreatoduodenectomy (PD) for cancer. Little is known about the long-term survival of patients after PPH. This retrospective study aimed to evaluate the impact of PPH on long-term survival after PD.

METHODS

The study included 830 patients (PPH, n = 101; non-PPH, n = 729) from two centers, who underwent PD for oncological indications. PPH was defined as any bleeding event occurring within 90 days after surgery. A flexible parametric survival model was used to determine the evolution of the risk of death over time.

RESULTS

At postoperative day 90, PPH significantly increased the mortality rate (PPH vs. non-PPH: 19.8% vs. 3.7%, p < 0.0001) and severe postoperative complication rate (85.1% vs. 14.1%, p < 0.0001), and decreased median survival (18.6 months vs. 30.1 months, p = 0.0001). PPH was associated with an increased mortality risk until the sixth postoperative month. After this 6-month period, PPH had no more influence on mortality.

CONCLUSIONS

PPH had a negative impact on the short-term overall survival beyond postoperative day 90 and up to six months after PD. However, compared to non-PPH patients, this adverse event had no impact on mortality after a 6-month period.

Management of severe peri-operative bleeding: Guidelines from the European Society of Anaesthesiology and Intensive Care: Second update 2022

BACKGROUND

Management of peri-operative bleeding is complex and involves multiple assessment tools and strategies to ensure optimal patient care with the goal of reducing morbidity and mortality. These updated guidelines from the European Society of Anaesthesiology and Intensive Care (ESAIC) aim to provide an evidence-based set of recommendations for healthcare professionals to help ensure improved clinical management.

DESIGN

A systematic literature search from 2015 to 2021 of several electronic databases was performed without language restrictions. Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used to assess the methodological quality of the included studies and to formulate recommendations. A Delphi methodology was used to prepare a clinical practice guideline.

RESULTS

These searches identified 137 999 articles. All articles were assessed, and the existing 2017 guidelines were revised to incorporate new evidence. Sixteen recommendations derived from the systematic literature search, and four clinical guidances retained from previous ESAIC guidelines were formulated. Using the Delphi process on 253 sentences of guidance, strong consensus (>90% agreement) was achieved in 97% and consensus (75 to 90% agreement) in 3%.

DISCUSSION

Peri-operative bleeding management encompasses the patient's journey from the pre-operative state through the postoperative period. Along this journey, many features of the patient's pre-operative coagulation status, underlying comorbidities, general health and the procedures that they are undergoing need to be taken into account. Due to the many important aspects in peri-operative nontrauma bleeding management, guidance as to how best approach and treat each individual patient are key. Understanding which therapeutic approaches are most valuable at each timepoint can only enhance patient care, ensuring the best outcomes by reducing blood loss and, therefore, overall morbidity and mortality.

CONCLUSION

All healthcare professionals involved in the management of patients at risk for surgical bleeding should be aware of the current therapeutic options and approaches that are available to them. These guidelines aim to provide specific guidance for bleeding management in a variety of clinical situations.

Risk factors for achieving textbook outcome after laparoscopic duodenum-preserving total pancreatic head resection: a retrospective cohort study

INTRODUCTION

The risk factors for achieving textbook outcome (TO) after laparoscopic duodenum-preserving total pancreatic head resection (LDPPHR-t) are unknown, and no relevant articles have been reported so far. The aim of this study was to identify the risk factors for achieving TO after LDPPHR-t.

METHODS

The risk factors for achieving TO after LDPPHR-t were retrospectively evaluated by logistic regression analysis in 31 consecutive patients from May 2020 to December 2021.

RESULTS

All LDPPHR-t procedures were successfully performed without conversion. There was no death within 90 days after surgery and no readmission within 30 days after discharge. The percentage of achieving TO after LDPPHR-t was 61.3% (19/31). Among the six TO items, the postoperative complication of grade B/C postoperative pancreatic fistula (POPF) occurred most frequently with 22.6%, followed by grade B/C bile leakage with 19.4%, Clavien-Dindo≥III complications with 19.4%, and grade B/C postpancreatectomy hemorrhage with 16.1%. POPF was the major obstacle to achieve TO after LDPPHR-t. Placing an endoscopic nasobiliary drainage (ENBD) catheter and prolonged operation time (>311 min) were significantly associated with the decreased probability of achieving TO after LDPPHR-t (odd ratio (OR), 25.775; P =0.012 and OR, 16.378; P =0.020, respectively). Placing an ENBD catheter was the only significant independent risk factor for POPF after LDPPHR-t (OR, 19.580; P =0.017). Bile leakage was the independent risk factor for postpancreatectomy hemorrhage after LDPPHR-t (OR, 15.754; P =0.040). The prolonged operation time was significantly correlated with Clavien-Dindo grade≥III complications after LDPPHR-t (OR, 19.126; P =0.024).

CONCLUSION

Placing the ENBD catheter was the independent risk factor for POPF and achieving TO after LDPPHR-t. In order to reduce POPF and increase the probability of achieving TO, placing an ENBD catheter should be avoided prior to LDPPHR-t.

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.

Arterial reinforcement following pancreatoduodenectomy: The solution to prevent delayed hemorrhage caused by postoperative pancreatic fistula

PURPOSE

Delayed hemorrhage (DH) is a rare and yet well-known fatal complication associated with postoperative pancreatic fistula (POPF) in pancreatoduodenectomy (PD). The study aimed to investigate whether arterial reinforcement (AR) using polyglycolic acid sheets (PAS) followed by fibrin sealant (FS) to the hepatic artery could prevent DH in the setting of POPF after PD.

METHODS

A total of 345 patients underwent PD for periampullary tumors from March 2011 to March 2022. From March 2011 to March 2018, 225 patients underwent PD, and AR was not performed (non-AR group). From April 2018 to March 2022, 120 patients underwent PD, and AR was performed (AR group). AR was achieved by wrapping the proper hepatic artery all the way down to the celiac artery with PAS followed by coating with FS. Demographic profile and various outcomes including DH of these two groups were compared and analyzed retrospectively.

RESULTS

In non-AR group, 48 (21.3%) and 12 (5.3%) patients had grade B and C POPF, respectively. In AR group, 26 (21.7%) and four (3.3%) patients had grade B and C POPF, respectively. The incidence of POPF was not statistically significant (p = .702) between the groups. Among the patients with grade B or C POPF, DH occurred in 14 (23.3%) patients in non-AR group and only one patient in AR group (p = .016). Of the 15 patients with DH, four (26.7%) patients died.

CONCLUSION

AR using PAS and FS is effective in preventing DH in the setting of POPF.

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.

Spontaneous cessation of postpancreatectomy hemorrhage in a patient with celiac artery stenosis

Postpancreatectomy hemorrhage (PPH) is a severe complication of pancreatic surgery. This condition often develops on the background of pancreatic fistula. In our report, we demonstrate an unusual case of spontaneous cessation of severe postpancreatectomy common hepatic artery (СHA) hemorrhage after distal pancreatectomy in a patient with celiac artery stenosis (CAS). A 64-year-old male diagnosed with pancreatic tail tumor underwent extended distal pancreatectomy. He developed pancreatic fistula and was discharged with an abdominal drain, and was readmitted with severe postpancreatectomy hemorrhage from a pseudoaneurysm of the CHA. The bleeding stopped spontaneously due to CHA thrombosis. The patient developed no ischemic symptoms. Spontaneous severe postpancreatectomy hemorrhage cessation is an extremely rare phenomenon. Vascular anomalies must be considered when attempting interventional radiology treatment. CHA probably may be sacrificed with no ischemic consequences in case of severe hemorrhage in patients with CAS.

A systematic review of post-pancreatectomy haemorrhage management stratified according to ISGPS grading

BACKGROUND

Morbidity and mortality from post-pancreatectomy haemorrhage (PPH) remains high. The International Study Group of Pancreatic Surgery (ISGPS) published guidelines to standardise definitions of PPH severity, management and reporting. This study aimed to i) identify the number of studies reporting PPH using ISGPS guidelines (Grade A, B or C) and ii) describe treatment modality success by grade.

METHODS

A systematic literature review was performed, identifying studies reporting PPH by ISGPS Grade and their subsequent management.

RESULTS

Of 62 studies reporting on PPH management, 17 (27.4%) stratified by ISGPS guidelines and included 608 incidences of PPH: 48 Grade A, 274 Grade B (62 early, 166 late, 46 unspecified) and 286 Grade C. 96% of Grade A PPH were treated conservatively. Of 62 early Grade B, 54.8% were managed conservatively and 37.1% surgically. Late Grade B were managed non-operatively in 25.3% (42/166), with successful endoscopy in 90.9% (10/11) and angiography in 90.3% (28/31). In Grade C, endoscopic treatment was successful in 64.4% (29/45) and angiography in 90.8% (108/119). Surgical intervention was required in 43.5% early Grade B, 7.8% late Grade B and 33.2% Grade C.

CONCLUSION

PPH grading is underreported and despite guidelines, inconsistencies remain when using definitions and reporting of outcomes.

Case report of Modified Viabahn Open Revascularization TEChnique (VORTEC) as a rescue strategy for hepatic artery dissection after initial endovascular treatment of postpancreaticoduodenectomy hemorrhage

RATIONALE

Currently endovascular treatments are commonly utilized to treat postpancreaticoduodenectomy hemorrhage. However, when endovascular procedure went wrong, open surgery with ligation of the culprit vessels would be the most common salvage method. With Modified Viabahn Open Revascularization TEChnique (VORTEC), we can try to rescue the vessel without sacrificing it by introduction of another endovascular stent under direct method.

PATIENT CONCERNS

A 76-year-old man with stage IIIA ampulla vater adenocarcinoma underwent pancreaticoduodenectomy and experience pancreatic leak complicated with postpancreaticoduodenectomy hemorrhage.

DIAGNOSIS

Emergent angiography revealed extravasation from proper hepatic artery.

INTERVENTIONS

A 6 mm Viabahn stent was deployed but no distal runoff. Operation was shifted to emergent laparotomy and revealed intimal dissection of hepatic artery. Modified VORTEC was performed with guidewire redirected to true lumen and another stent was deployed under direct vision.

OUTCOMES

Patient's hepatic artery was preserved and with no consequent liver failure.

LESSON

Modified VORTEC method could be used as salvage strategy for artery dissection after initial endovascular treatment failed.

Evaluation of Open Surgical and Endovascular Treatment Options for Visceral Artery Erosions after Pancreatitis and Pancreatic Surgery

Purpose: To report and compare the results of endovascular and open surgical treatment for erosion bleeding of visceral arteries following pancreatitis and pancreatic surgery. Materials and Methods: This retrospective study included 65 consecutive patients (46 males, mean age 63 ± 14 years) presenting with visceral artery erosions between January 2011 and December 2020. Endpoints were technical success, freedom from reintervention, stent-graft-related complications, and 30-day and one-year mortality. Results: The causes of erosion bleeding included complications of surgical treatment for the pancreas and upper gastrointestinal tract (75%), pancreatitis (19%), and spontaneous bleeding (6%). Pancreatectomy was performed in 34 (52%) patients, representing 2% of all pancreatectomy procedures (n = 1645) performed in our hospital during the study period. A total of 37 (57%) patients underwent endovascular treatment (EVT), and 28 (43%) patients had open surgery (OS) as a primary treatment. Eight of 37 (22%) patients in the EVT group underwent stent-graft treatment of the eroded vessels and 28 (78%) coil embolization. Six (9%) patients underwent reintervention with no significant differences between EVT and OS groups (11% vs. 7%, p = 0.692). Postoperative morbidity and complications in 52% of all patients were higher in the OS group than in the EVT group (41% vs. 68%, p = 0.029). The in-hospital 30-days mortality rate for all patients was 25%, and it was higher in the OS group than in the EVT group (14% vs. 39%, p = 0.017). Conclusions: An endovascular-first strategy for treating visceral arteries erosions may be preferred to reduce the complications associated with open surgery if patients are hemodynamically stable and have no anastomotic insufficiency. Endovascular treatment may be associated with better in-hospital survival when compared to primary open surgery. Further studies are required to identify the optimal approach.

C-reactive protein identifies patients at risk of postpancreatectomy hemorrhage

Background

Postpancreatectomy hemorrhage grade C (PPH C) is a dreaded complication after pancreaticoduodenectomy (PD) with high mortality rate. Concurrent risk factors for PPH C have been difficult to recognize. Connection between postoperative pancreatic fistulas (POPF) and PPH C is well known, but POPF is often unknown prior to the PPH. The aim of this retrospective study was to define potential predictive factors for PPH C.

Methods

Retrospectively, 517 patients who underwent PD between 2003 and 2018 were included in the study. Twenty-three patients with PPH C were identified, and a matched control group of 92 patients was randomly selected. Preoperative data (body mass index, cardiovascular disease, history of abdominal surgery, biliary stent, C-reactive protein (CRP), ASA-score), perioperative data (bleeding, pancreatic anastomosis, operation time), and postoperative data (CRP, drain amylase, POPF, biliary fistula) were analyzed as potential predictors of PPH C.

Results

High postoperative CRP (median 140 mg/L on day 5 or 6) correlated with the development of PPH C (p < 0.05). Postoperative drain amylase levels were not clinically relevant for occurrence of PPH C. Grade C POPF or biliary leak was observed in the majority of the PPH C patients, but the leaking anastomoses were not detected before the bleeding started.

Discussion

High postoperative CRP levels are related to an increased risk of PPH C.

Postoperative Outcome of Surgery with Pancreatic Resection for Retroperitoneal Soft Tissue Sarcoma: Results of a Retrospective Bicentric Analysis on 50 Consecutive Patients

BACKGROUNDS

Multivisceral resection is the standard treatment for retroperitoneal sarcoma (RPS) during which pancreas resection may be necessary.

METHODS

All consecutive patients operated for RPS with pancreatectomy in 2 expert centers between 1993 and 2018 were retrospectively analyzed.

RESULTS

Fifty patients (median age: 57 years, IQR: [46-65]) with a primary (n = 33) or recurrent (n = 17) RPS underwent surgery requiring pancreas resection (distal pancreatectomy (DP) (n = 43), pancreaticoduodenectomy (PD) (n = 5), central pancreatectomy (n = 1), and atypical resection (n = 1)). Severe postoperative morbidity (Clavien-Dindo III-IV) was observed in 14 patients (28%), and 7 of them (14%) required reoperation for anastomotic bowel leakage (n = 5), gastric volvulus (n = 1), or hemorrhage (n = 1). Pancreas-related complications occurred in 25 patients (50%): 10 postoperative pancreatic fistulas (POPF) (grade A (n = 12), grade B (n = 6), grade C (n = 1)), 13 delayed gastric emptying (grade A (n = 8), grade B (n = 4), grade C (n = 1)), 1 hemorrhage (grade C). Postoperative mortality was 4% (n = 2), all following PD, caused by a massive intraoperative air embolism and by a multiple organ failure after anastomotic leakage. Pathological analysis confirmed pancreatic involvement in 17 (34%) specimens. Microscopically complete resection (R0) was achieved in 22 (44%) patients. After a follow-up of 60 months, 36 patients (75%) were still alive, among whom 27 without recurrence (56%).

CONCLUSION

Pancreatic resection during RPS surgery is associated with significant postoperative morbidity and mortality. PD should be avoided whenever possible while other procedures seemed achievable without excessive morbidity and with long-term survival.

[Endovascular treatment of arterial bleeding after pancreatic surgery]

Pancreatic surgery is complex and associated with a risk of complications including bleeding. Bleeding after pancreatic surgery is rare, but characterized by high mortality. This review is devoted to classification, diagnosis and treatment strategies for bleeding after pancreatic surgery. Methods and results of endovascular surgery are of special attention.

Curing pancreatic cancer

The distinct biology of pancreatic cancer with aggressive and early invasive tumor cells, a tumor promoting microenvironment, late diagnosis, and high therapy resistance poses major challenges on clinicians, researchers, and patients. In current clinical practice, a curative approach for pancreatic cancer can only be offered to a minority of patients and even for those patients, the long-term outcome is grim. This bitter combination will eventually let pancreatic cancer rise to the second leading cause of cancer-related mortalities. With surgery being the only curative option, complete tumor resection still remains the center of pancreatic cancer treatment. In recent years, new developments in neoadjuvant and adjuvant treatment have emerged. Together with improved perioperative care including complication management, an increasing number of patients have become eligible for tumor resection. Basic research aims to further increase these numbers by new methods of early detection, better tumor modelling and personalized treatment options. This review aims to summarize the current knowledge on clinical and biologic features, surgical and non-surgical treatment options, and the improved collaboration of clinicians and basic researchers in pancreatic cancer that will hopefully result in more successful ways of curing pancreatic cancer.

Late postpancreatectomy hemorrhage from the gastroduodenal artery stump into an insufficient hepaticojejunostomy: a case report

Background

Mortality after elective pancreatic surgery in modern high-volume centers is very low. Morbidity remains high, affecting 20–40% of patients. Late postpancreatectomy hemorrhage is a rare but potentially lethal complication. The exceptionality in our case lies in the underlying mechanism of its clinical presentation. It is a demonstration of the difficulties associated with finding the source of bleeding in late postpancreatectomy hemorrhage.

Case presentation

An 82-year-old White female was diagnosed with a periampullary malignancy and underwent pancreatoduodenectomy. Postoperatively, the patient suffered from an anastomotic leak in the hepaticojejunostomy, which was treated with percutaneous pigtail drains in the abdomen and in the biliary tract. On the fourth postoperative week she presented blood in both drains and in her stool. Given our knowledge about the biliary anastomotic leak, this presentation led us to suspect an intraluminal source (biliary tract or gastrojejunostomy) with blood leaking through the insufficient hepaticojejunostomy into the abdominal cavity. Upper tract endoscopy and computed tomography angiography were, however, unremarkable. Further investigation with conventional angiography identified the bleeding source at the gastroduodenal artery stump, which was successfully coiled. Hence, the gastroduodenal artery stump was bleeding into the insufficient hepaticojejunostomy, filling up the biliary tree and the small intestine. After coiling of the artery, the remainder of the postoperative care was uneventful.

Conclusion

Postpancreatectomy hemorrhage presents a major clinical challenge after pancreatoduodenectomy, with significant morbidity and high risk for mortality. The treating physician must be alert and active in the investigation and treatment of the bleeding source to ensure a successful outcome.

Delayed post-pancreatectomy hemorrhage and bleeding recurrence after percutaneous endovascular treatment: risk factors from a bi-centric study of 307 consecutive patients

PURPOSE

Delayed post-pancreatectomy hemorrhage (PPH) is still one of the most dreaded complications after pancreatic surgery. Its management is now focused on percutaneous endovascular treatments (PETs).

METHODS

Between 2013 and 2019, 307 patients underwent pancreatic resection. The first endpoint of this study was to determine predictive factors of delayed PPH. The second endpoint was to describe the management of intra-abdominal abscesses (IAA). The third endpoint was to identify risk factors of bleeding recurrence after PET. Patients were divided into two cohorts: A retrospective analysis was performed ("cohort 1," "learning set") to highlight predictive factors of delayed PPH. Then, we validated it on a prospective maintained cohort, analyzed retrospectively ("cohort 2," "validation set"). Second and third endpoints studies were made on the entire cohort.

RESULTS

In cohort 1, including 180 patients, 24 experienced delayed PPH. Multivariate analysis revealed that POPF diagnosis on postoperative day (POD) 3 (p=0.004) and IAA (p=0.001) were independent predictive factors of delayed PPH. In cohort 2, association of POPF diagnosis on POD 3 and IAA was strongly associated with delayed PPH (area under the curve [AUC] 0.80; 95% confidence interval [CI] [0.59-0.94]; p=0.003). Concerning our second endpoint, delayed PPH occurred less frequently in patients who underwent postoperative drainage procedure than in patients without IAA drainage (p=0.002). Concerning our third endpoint, a higher body mass index (BMI) (p=0.027), occurrence of postoperative IAA (p=0.030), and undrained IAA (p=0.011) were associated with bleeding recurrence after the first PET procedure.

CONCLUSION

POPF diagnosis on POD 3 and intra-abdominal abscesses are independent predictive factors of delayed PPH. Therefore, patients presenting an insufficiently drained POPF leading to intra-abdominal abscess after pancreatic surgery should be considered as a high-risk situation of delayed PPH. High BMI, occurrence of postoperative IAA, and undrained IAA were associated with recurrence of bleeding after PET.

Impact of vascular abnormality on contrast-enhanced CT and high C-reactive protein levels on postoperative pancreatic hemorrhage after pancreaticoduodenectomy: A multi-institutional, retrospective analysis of 590 consecutive cases

BACKGROUND

/Objectives: This study aimed to elucidate the efficacy of CT findings and perioperative characteristics to predict post-pancreatectomy hemorrhage (PPH): a critical complication after pancreaticoduodenectomy.

METHODS

The records of 590 consecutive patients who underwent pancreaticoduodenectomy at three institutes between 2012 and 2018 were included. The presence of a vascular wall abnormality or ascites with high density (vascular abnormality) on postoperative day (POD) 5-10 contrast-enhanced CT (early CT), perioperative characteristics, and any PPH or pseudoaneurysm formation (PPH events) were analyzed through a multivariate analysis.

RESULTS

PPH events occurred in 48 out of 590 patients (8%). The vascular abnormality on early CT and the C-reactive protein (CRP) value on POD 3 were independent risk factors for PPH events after POD5 (vascular abnormality: odds ratio 6.42, p = 0.001; CRP on POD 3: odds ratio 1.17, p = 0.016). The sensitivity of vascular abnormality for PPH events was 24% (7/29), and the positive predictive value was 30% (7/23). The combination of vascular abnormality and a high CRP value (≥15.5 mg/dL) on postoperative day 3 had a higher positive predictive value of 64% (7/11) than the vascular abnormality alone. None of the seven PPH events that occurred more than one month after surgery were foreseen via early CT.

CONCLUSION

The combination of vascular abnormality and high CRP value was associated with increasing risk of PPH events after pancreaticoduodenectomy, but the low sensitivity of early CT must be noted as an important shortcoming. The normal findings on early CT could not eliminate the risk of late PPH.

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.

Bleeding from the pancreatic cut surface post pancreaticoduodenectomy: a review of a tertiary referral centre

BACKGROUND

Haemorrhage from the pancreatic cut surface after pancreaticoduodenectomy is uncommon. The optimal treatment for post-pancreatectomy haemorrhage (PPH) from the pancreatic cut surface remains controversial.

METHODS

We performed a retrospective analysis including all patients who underwent a pancreatiocoduodenectomy between 2008 and 2018 at a single tertiary institution in Melbourne, Australia, to analyse the incidence, potential risk factors, treatment and outcomes of cut surface PPH.

RESULTS

A total of 168 pancreaticoduodenectomies were performed during the study period with pancreaticogastrostomy being the most common method of reconstruction at our institution (84.5%). There were 12 instances of cut surface PPH (7.1%). The majority of cases of cut surface PPH occurred within 48 h following pancreaticoduodenectomy (67%) with 41.7% occurring in the first 24 h. All but one patient required surgical intervention but length of stay did not appear to be increased compared to those without cut surface PPH. There was a trend towards patients with cut surface PPH being more likely to have a non-dilated pancreatic duct (75% versus 49%; P = 0.079). No significant differences were noted between patient with and without cut surface PPH with regards to abnormalities in platelet counts (3.2% versus 0%; P = 0.529), international normalized ratio (4.5% versus 8.3%; P = 0.694) and prophylactic anticoagulant administration or continuing antiplatelet use (28.2 versus 16.7%; P = 0.630).

CONCLUSION

We believe that an unobstructed pancreas, in combination with the acidic environment associated with a dunking pancreaticogastrostomy anastomosis, may predispose to bleeding from the cut surface of the pancreas.

Complete embolisation of the proper hepatic artery for delayed haemorrhage after pancreaticoduodenectomy: a case report

Postpancreatectomy haemorrhage (PPH) is a rare and life-threatening complication that can occur after pancreaticoduodenectomy (PD). Recently, radiological intervention has become a first-line approach for the diagnosis and treatment of late PPH in haemodynamically stable patients. Surgical intervention should be performed in haemodynamically unstable patients. We report the case of a 54-year-old man who underwent PD for ampullary carcinoma. On postoperative day (POD) 20, he developed a late PPH in the context of pancreatic fistula that was accompanied by hypotension and tachycardia. Therefore, emergency relaparotomy was performed, but the bleeding site was not detected due to severe adhesions in the surgical field. Thus, urgent angiography was performed immediately, and active bleeding was detected from the distal part of the proper hepatic artery. Coil embolisation of the proper hepatic artery trunk was successfully performed. No intrahepatic abscess or liver failure was subsequently observed, and the patient left our hospital on POD 27. This case shows that radiological intervention is a first choice for the diagnosis and treatment of haemodynamically stable late PPH and that it also might still be a first choice and also be safer and more effective than surgical intervention even with unstable haemodynamics.

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.

Practice patterns of VTE chemoprophylaxis after discharge following hepatic and pancreatic resections for cancer: A survey of hepatopancreatobiliary surgeons

Patients with hepatopancreatobiliary (HPB) malignancies undergoing resection are prone to venous thromboembolism (VTE), and current guidelines recommend up to 28 days of chemoprophylaxis after major surgery. We sought to determine the practice patterns among HPB surgeons for use of chemoprophylaxis after discharge. A survey on VTE chemoprophylaxis after oncologic HPB operations was distributed to attending surgeons at the 18 HPB fellowship training programs in the United States and Canada. Of the HPB surgeons surveyed, 44 (44%) responded. VTE prophylaxis is used by 93% of respondants in the inpatient postoperative setting. Chemoprophylaxis after discharge for pancreaticoduodenenctomy and distal pancreatectomy is utilized by 45% and 39% of respondants, respectively. Of those who prescribe chemoprophylaxis after discharge, 79% and 88% prescribe it for the recommended 28 days after pancreaticoduodenectomy and distal pancreatectomy, respectively. Chemoprophylaxis after discharge for major and minor hepatectomy is utilized by 39% and 26% of respondents, respectively. Of those who prescribe chemoprophylaxis after discharge, 67% and 55% provide it for the recommended 28 days after major and minor hepatectomy, respectively. Despite documented prolonged postoperative thrombogenic risk, the use of chemoprophylaxis following discharge after pancreatic and liver resections for cancer was moderate among surveyed HPB surgeons.

Bleeding complications after pancreatic surgery: interventional radiology management

Surgical intervention in the pancreas region is complex and carries the risk of complications, also of vascular nature. Bleeding after pancreatic surgery is rare but characterized by high mortality. This review reports epidemiology, classification, diagnosis and treatment strategies of hemorrhage occurring after pancreatic surgery, focusing on the techniques, roles and outcomes of interventional radiology (IR) in this setting. We then describe the roles and techniques of IR in the treatment of other less common types of vascular complications after pancreatic surgery, such as portal vein (PV) stenosis, portal hypertension and bleeding of varices.

Prognosis of sporadic resected small (≤2 cm) nonfunctional pancreatic neuroendocrine tumors - a multi-institutional study

BACKGROUND

Malignant potential of small (≤20 mm) nonfunctional pancreatic neuroendocrine tumors (sNF-PNET) is difficult to predict and management remain controversial. The aim of this study was to assess the prognosis of sporadic nonmetastatic sNF-PNETs.

METHODS

Patients were identified from databases of 16 centers. Outcomes and risk factors for recurrence were identified by uni- and multivariate analyses.

RESULTS

sNF-PNET was resected in 210 patients, and 66% (n = 138) were asymptomatic. Median age was 60 years, median tumor size was 15 mm, parenchyma-sparing surgery was performed in 42%. Postoperative mortality was 0.5% (n = 1), severe morbidity rate was 14.3% (n = 30), and 14 of 132 patients (10.6%) with harvested lymph nodes had metastatic lymph nodes. Tumor size, presence of biliary or pancreatic duct dilatation, and WHO grade 2-3 were independently associated with recurrence. Patients with tumors sized ≤10 mm were disease free at last follow-up. The 1-, 3- and 5-year disease-free survival rates for patients with tumors sized 11-20 mm on preoperative imaging were 95.1%, 91.0%, and 87.3%, respectively.

CONCLUSIONS

In sNF-PNETs, the presence of biliary or pancreatic duct dilatation or WHO grade 2-3 advocate for surgical treatment. In the remaining patients, a wait-and-see policy might be considered.

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

Delayed post-pancreatectomy hemorrhage (PPH) is a relatively uncommon, but feared, complication after pancreaticoduodenectomy (PD). A splenic artery pseudoaneurysm is a rare cause of delayed PPH after a PD. This paper describes the case of a patient with PD used to treat a distal bile duct cholangiocarcinoma complicated with a clinically significant pancreatic fistula and secondary intraabdominal abscess. Computed tomography-guided drainage of the abscess was performed with an apparently favourable outcome; the patient was discharged on postoperative day (POD) 35 and the abdominal drains were removed on POD 50. On POD 80, the patient was readmitted for a severe digestive hemorrhage. Computed tomography revealed a pseudoaneurysm of the splenic artery with a subsequent hematoma formation. Immediately, an angiography was performed and coils were successfully mounted. This case illustrates the rare possibility of the development of a splenic artery pseudoaneurysm with severe delayed PPH after PD complicated with a clinically significant pancreatic fistula, even after the patient was discharged from the hospital. An interventional radiology approach represents the first treatment option in hemodynamically stable patients with high success rates.