Transcatheter arterial embolization of gastroduodenal artery stump pseudoaneurysms after pancreaticoduodenectomy: safety and efficacy of two embolization techniques

Endovascular management of two episodes of late intraperitoneal hemorrhage following laparoscopic gastrectomy for gastric cancer

Endovascular treatment for hemorrhagic complications following surgery has recently gained wide acceptance due to its minimal invasiveness compared to surgery. A 56-year-old male patient underwent laparoscopic gastrectomy for gastric cancer. There were two episodes of late intraperitoneal hemorrhage and endovascular treatment was performed. Transcatheter coil embolization of the gastroduodenal artery stump was successful in controlling the bleeding initially; however, hemorrhage recurred 7 days later. Repeated angiography revealed an obvious hemorrhage from the right gastric artery stump and embolization of the hepatic artery proper was performed to achieve immediate hemostasis. The endovascular treatment process was analyzed and the literature on similar situations was reviewed. In the present case, endovascular procedures were performed successfully to control bleeding in two episodes of late intraperitoneal hemorrhage. Angiography is recommended as the first-line modality for late intraperitoneal hemorrhage following laparoscopic gastrectomy and transcatheter coil embolization of the hepatic artery proper is safe and effective in selected cases.

Postoperative complications influence prognosis and recurrence patterns in periampullary cancer

BACKGROUND

The present study was performed to elucidate the influence of postoperative complications on the prognosis and recurrence patterns of periampullary cancer after pancreaticoduodenectomy (PD).

METHODS

Clinical data were reviewed from 200 consecutive patients who had periampullary cancer and underwent PD between October 2003 and July 2010, and survival outcomes and recurrence patterns were analyzed. Postoperative complications were classified according to a modification of Clavien's classification.

RESULTS

Overall, 86 major complications of grade II or higher occurred in 71 patients. The patients were classified into two groups according to the presence of postoperative complications of grade II or higher: group Cx-, absence of complications (n = 129); and group Cx+, presence of complications (n = 71). There were no differences in gender, mean age, tumor node metastasis stage, biliary drainage, type of resection, and radicality between the two groups (P > 0.05). The 3-year overall and disease-free survival rates of the group Cx+ patients (31.0 and 22.3 %, respectively) were significantly lower than those of the group Cx- patients (49.0 and 40.0 %; P = 0.003 and 0.002, respectively). The multivariate analysis showed that postoperative complications (P = 0.001; RR = 1.887; 95 % confidence interval [CI] 1.278-2.785), a T stage of T3 or T4 (P = 0.001; RR = 2.503; 95 % CI 1.441-4.346), positive node metastasis (P = 0.001; RR = 2.093; 95 % CI, 1.378-3.179), R1 or R2 resection (P = 0.023; RR = 1.863; 95 % CI 1.090-3.187), and angiolymphatic invasion (P = 0.013; RR = 1.676; 95 % CI 1.117-2.513) were independent prognostic factors for disease-free survival. Regarding recurrence patterns, group Cx+ patients exhibited more distant recurrences than did group Cx- patients (P = 0.025).

CONCLUSIONS

Postoperative complications affect prognosis and recurrence patterns in patients with periampullary cancer after PD.

Peripancreatic pseudoaneurysms: a management-based classification system

BACKGROUND

Peripancreatic pseudoaneurysms can arise in a number of different clinical settings but are associated mostly with pancreatitis and pancreatobiliary surgery. The aim of this study is to review the current literature and to propose a management classification system based on the pathophysiological processes and the exact anatomical site of peripancreatic pseudoaneurysms.

METHODS

A systematic review of the literature from 1995 to 2012 was performed. Articles on studies describing peripancreatic pseudoaneurysms in the setting of pancreatitis or major hepatic or pancreatic surgery with more than ten patients were included. Seventeen eligible studies were identified and reviewed.

RESULTS

The demographic characteristics of the patients in all studies were similar with a predominance of males and a mean age of 55 years. The overall mortality rate varied greatly among the studies, ranging from 0 to 60%. Embolisation was the first line of management in the majority of the studies, with surgery reserved for failed embolisation or for haemodynamically unstable cases. Embolisation of the hepatic artery or its branches was associated with high rates of morbidity (56%) and hepatic failure (19%). More recent studies show that stents are used increasingly for vessels that cannot be embolised safely. Late bleeding, a major cause of mortality and morbidity, is generally underreported. The proposed classification system is based on three factors: (1) the type of artery from which the pseudoaneurysm arises, (2) whether communication with the gastrointestinal tract is present, and (3) whether there is high concentration of pancreatic juice at the bleeding site.

CONCLUSION

The management of peripancreatic pseudoaneurysms usually comprises a combination of interventional radiology and surgery and this may be assisted by a logical classification system.

Pseudoaneurysm of the gastroduodenal artery following pancreatoduodenectomy. Stenting for hemorrhage

Postpancreatectomy hemorrhage (PPH) and pancreatic fistula are main and serious complications following pancreaticoduodenectomy. Postpancreatectomy hemorrhage is considered life-threatening for its high rate of mortality. Postpancreatectomy hemorrhage is defined as early, occurring within 24 h after surgery, and late. The authors present a case of late PPH which developed in the third week following pylorus-preserving pancreaticoduodenectomy. A 58-year-old man was operated on for cancer of the pancreatic head. Hemorrhage occurred when the patient was in full health, convalescing at home. The cause was bleeding from a pseudoaneurysm of the stump of the gastroduodenal artery directly into the gastrointestinal tract. Diagnosis was established based on computed tomography angiography. Treatment was performed using minimally invasive technique during angiography. The implantation of a stent graft into the common hepatic artery for bridging the stump of the gastroduodenal artery was performed. This method thus enabled at once both diagnosis and successful minimally invasive treatment.

Interventional radiology and the pancreatic cancer patient

Patients with pancreatic cancer have a dismal prognosis. This article reviews the role that interventional radiology can play in managing postoperative complications and in patient palliation, particularly with an obstructed biliary system. In addition, options for cytoreduction are discussed, including chemoembolization, radioembolization, and thermal ablation. The final option reviewed is irreversible electroporation, which is being explored as a technique to allow patients with locally advanced pancreatic cancer to be converted to surgical candidates.

Post-pancreaticoduodenectomy hemorrhage of unusual origin: treatment with endovascular embolization and the value of preoperative CT angiography

Post-pancreaticoduodenectomy hemorrhage is a life threatening complication reported to occur in 2-7% of patients. Historically, treatment required an exploratory laparotomy. Introduction of endovascular embolization has broadened the available treatment options. The most common location for a post-pancreaticoduodenectomy hemorrhage is the gastroduodenal artery stump. Nonetheless, unusual sources of hemorrhage exist and are hard to localize, thus they are often treated with open surgery. Here we report two cases of CTA proven hemorrhage from the dorsal pancreatic arcade and transverse pancreatic artery, which were successfully located with conventional angiography and treated with endovascular arterial coil embolization. Both patients were status post-pancreaticoduodenectomy (Whipple procedure) and presented with a sentinel bleed and a drop in hematocrit levels.

A challenging case of epigastric pain: diagnosis and mini-invasive treatment of a large gastroduodenal artery pseudoaneurysm

The authors present a case of a gastroduodenal artery pseudoaneurysm in a patient with a medical history of pancreatic surgery. The lesion was found and evaluated by ultrasound, CT-angiography and then treated with trans-catheter embolisation. This mini-invasive approach led to a complete resolution of the lesion.

Clinical features and management of pseudoaneurysmal bleeding after pancreatoduodenectomy

A ruptured pseudoaneurysm is the most serious and life-threatening cause of postpancreatoduodenectomy (PD) hemorrhages. We have evaluated the clinical course and management of pseudoaneurysms after PD. Of 586 patients who underwent PD for periampullary tumors in Asan Medical Center between March 2003 and March 2011, 27 experienced pseudoaneurysmal bleeding. Bleeding developed at a median of 21 days (range, 8 to 45 days) after surgery, including 9 patients who developed bleeding more than 4 weeks after surgery. Before development of bleeding, 26 patients showed pancreatic fistula. Bleeding was developed from the gastroduodenal artery stump in 12 patients, the common hepatic artery in eight, the proper hepatic artery in five, and the left hepatic artery in two. Of the angiographic group, 21 patients underwent with microcoil embolization, four underwent stent insertion, and one experienced technical failure. Only one patient required emergent laparotomy without angiography. Of 25 patients with angiographic procedures, all patients achieved hemostasis. The mortality rate was 22.2 per cent (6 patients). Delayed hemorrhage after PD is closely associated with pancreatic fistula and carried a significantly higher mortality rate. The patients with pancreatic fistula should be carefully monitored, even more than 4 weeks after surgery. Selective microcoil embolization or stent graft is effective for pseudoaneurysmal bleeding.