1
|
Marique L, Codjia T, Dembinski J, Dokmak S, Aussilhou B, Jehaes F, Cauchy F, Lesurtel M, Sauvanet A. Retromesenteric omental flap as arterial coverage in pancreaticoduodenectomy: A novel technique to prevent postpancreatectomy hemorrhage. Surgery 2024:S0039-6060(24)00204-6. [PMID: 38760227 DOI: 10.1016/j.surg.2024.03.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 12/30/2023] [Accepted: 03/24/2024] [Indexed: 05/19/2024]
Abstract
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.
Collapse
Affiliation(s)
- Lancelot Marique
- Department of HPB Surgery and Liver Transplantation, Beaujon Hospital, APHP, University of Paris Cité, Clichy, France
| | - Tatiana Codjia
- Department of HPB Surgery and Liver Transplantation, Beaujon Hospital, APHP, University of Paris Cité, Clichy, France
| | - Jeanne Dembinski
- Department of HPB Surgery and Liver Transplantation, Beaujon Hospital, APHP, University of Paris Cité, Clichy, France
| | - Safi Dokmak
- Department of HPB Surgery and Liver Transplantation, Beaujon Hospital, APHP, University of Paris Cité, Clichy, France
| | - Beatrice Aussilhou
- Department of HPB Surgery and Liver Transplantation, Beaujon Hospital, APHP, University of Paris Cité, Clichy, France
| | - François Jehaes
- Department of HPB Surgery and Liver Transplantation, Beaujon Hospital, APHP, University of Paris Cité, Clichy, France
| | - François Cauchy
- Department of HPB Surgery and Liver Transplantation, Beaujon Hospital, APHP, University of Paris Cité, Clichy, France
| | - Mickaël Lesurtel
- Department of HPB Surgery and Liver Transplantation, Beaujon Hospital, APHP, University of Paris Cité, Clichy, France
| | - Alain Sauvanet
- Department of HPB Surgery and Liver Transplantation, Beaujon Hospital, APHP, University of Paris Cité, Clichy, France.
| |
Collapse
|
2
|
Alfaifi J, Buisset C, Postillon A, Orry X, Chanty H, Germain A, Ayav A. Unusual massive venous hemorrhage after pancreatoduodenectomy treated by endovascular approach. J Surg Case Rep 2024; 2024:rjae256. [PMID: 38752152 PMCID: PMC11095255 DOI: 10.1093/jscr/rjae256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Accepted: 04/02/2024] [Indexed: 05/18/2024] Open
Abstract
Most post-pancreaticoduodenectomy hemorrhages (PPH) are of arterial origin, and some studies have suggested that an interventional radiology approach is most effective in reducing mortality. Venous PPH is rare, and identifying its source can be challenging. We report a case of late venous PPH in the context of a pancreatic fistula following pancreaticoduodenectomy. During surgical exploration, the area of potential bleeding was inaccessible due to major inflammatory adhesions aggravated by the presence of pancreatic fistula and the delay of relaparotomy. No intra-abdominal bleeding was detected on imaging studies or during abdominal exploration; only a massive bleeding through the drain orifice, which required packing, was observed. Percutaneous transhepatic portography was performed to localize and treat the origin of the bleeding. The hemorrhage was successfully treated by endovascular approach. We found no reports in the literature on the use of interventional radiology with venous stenting to treat venous PPH, except in cases of gastrointestinal variceal hemorrhage due to portal occlusion.
Collapse
Affiliation(s)
- Jaber Alfaifi
- Department of Digestive, Endocrine and Metabolic Surgery, Hôpital Robert Schuman – UNEOS Groupe Hospitalier Associatif, rue du Champ Montoy, Metz 57070, France
| | - Cyrille Buisset
- Department of Digestive, Endocrine and Metabolic Surgery, Hôpital Robert Schuman – UNEOS Groupe Hospitalier Associatif, rue du Champ Montoy, Metz 57070, France
| | - Agathe Postillon
- Department of Digestive Surgery, Hôpital Bel-Air – CHR Metz-Thionville, rue du Friscaty, Thionville 57100, France
| | - Xavier Orry
- Department of Radiology, University Hospital of Nancy, rue du Moran, Vandoeuvre-les, 54500 Nancy, France
| | - Hervé Chanty
- Department of Hepatobiliary, Colorectal and Oncologic Surgery, University Hospital of Nancy, rue du Moran, Vandoeuvre-les-Nancy 54500 Nancy, France
| | - Adeline Germain
- Department of Hepatobiliary, Colorectal and Oncologic Surgery, University Hospital of Nancy, rue du Moran, Vandoeuvre-les-Nancy 54500 Nancy, France
| | - Ahmet Ayav
- Department of Hepatobiliary, Colorectal and Oncologic Surgery, University Hospital of Nancy, rue du Moran, Vandoeuvre-les-Nancy 54500 Nancy, France
| |
Collapse
|
3
|
Hang K, Wei L, Yi M, Liu H, Huang Y, Zhang H, Tan C, Li K, Xiong J. Pedicled ligament flaps during pancreatoduodenectomy are associated with reduced hemorrhage from hepatic artery and gastroduodenal artery stump during pancreatoduodenectomy: a systematic review, meta-analysis and trial sequential analysis. HPB (Oxford) 2024; 26:476-485. [PMID: 38195309 DOI: 10.1016/j.hpb.2023.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 08/12/2023] [Accepted: 11/28/2023] [Indexed: 01/11/2024]
Abstract
BACKGROUND The aim of this study was to investigate whether pedicled ligament flaps (PLF) covering around the hepatic and gastroduodenal artery stump can provide better clinical outcomes in pancreatoduodenectomy (PD). METHODS We conducted a comprehensive search of databases (inception to January 2023) to identify studies comparing PD with or without PLF covering the skeletonized arteries. The perioperative and postoperative outcomes were compared. Pooled odds ratios (ORs) with 95 % confidence intervals (CIs) were calculated using fixed-effects models. RESULTS Ten studies were included in the qualitative synthesis. Six studies with 3538 patients met the inclusion criteria for the meta-analysis. Patients in the PLF group had a significantly lower rate of PPH from the hepatic artery or gastroduodenal artery stump (H/G PPH) (OR: 0.41; 95 % CI, 0.22-0.75; P < 0.01) and overall PPH (OR: 0.65; 95 % CI, 0.46-0.93; P = 0.02). There were no significant differences between the two groups in terms of morbidity, grade B/C postoperative pancreatic fistula (B/C POPF), delayed gastric emptying (DGE), reoperation, or mortality. CONCLUSION Prophylactic pedicled ligament flaps covering around the skeletonized arteries significantly reduced overall PPH and H/G PPH, and it seemed to have no obvious influence on other complications.
Collapse
Affiliation(s)
- Kuan Hang
- Division of Pancreatic Surgery, Department of General Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu 610041, Sichuan Province, China
| | - Lijuan Wei
- Division of Pancreatic Surgery, Department of General Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu 610041, Sichuan Province, China
| | - Mingchao Yi
- The People's Hospital of Jianyang City, Jianyang, Sichuan Province, China
| | - Haoheng Liu
- College of Medicine, Southwest Jiaotong University, Chengdu, Sichuan Province, China
| | - Yang Huang
- College of Medicine, Southwest Jiaotong University, Chengdu, Sichuan Province, China
| | - Hao Zhang
- Division of Pancreatic Surgery, Department of General Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu 610041, Sichuan Province, China
| | - Chunlu Tan
- Division of Pancreatic Surgery, Department of General Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu 610041, Sichuan Province, China
| | - Kezhou Li
- Division of Pancreatic Surgery, Department of General Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu 610041, Sichuan Province, China
| | - Junjie Xiong
- Division of Pancreatic Surgery, Department of General Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu 610041, Sichuan Province, China.
| |
Collapse
|
4
|
Endo I, Takahashi A, Tachimori H, Miyata H, Homma Y, Kumamoto T, Matsuyama R, Kakeji Y, Kitagawa Y, Seto Y. Requirements for hospitals in Japan to have low operative mortality and failure-to-rescue rates. Ann Gastroenterol Surg 2024; 8:342-355. [PMID: 38455494 PMCID: PMC10914696 DOI: 10.1002/ags3.12745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 08/31/2023] [Accepted: 09/13/2023] [Indexed: 03/09/2024] Open
Abstract
Aim We explored institutional factors in Japan associated with lower operative mortality and failure-to-rescue (FTR) rates for eight major gastrointestinal procedures. Methods A 22-item online questionnaire was sent to 2119 institutional departments (IDs) to examine the association between institutional factors and operative mortality and FTR rates. IDs were classified according to the number of annual surgeries, board certification status, and locality. In addition, the top 20% and bottom 20% of IDs were identified based on FTR rates and matched with the results of the questionnaire survey. Factors associated with operative mortality were selected by multivariate analysis. Results Of the 1083 IDs that responded to the questionnaire, 568 (213 382 patients) were included in the analysis. Operative morbidity, operative mortality, and FTR rates in the top 20% and bottom 20% of IDs were 13.1% and 8.4% (p < 0.001), 0.52% and 4.3% (p < 0.001), and 4.0% and 51.2% (p < 0.001), respectively. Based on the patients' background characteristics, the top 20% of IDs handled more advanced cases. No significant difference in locality was seen between better or worse hospital FTR rates, but fewer esophagectomies, hepatectomies, and pancreatoduodenectomies were performed in depopulated areas. Six items were found to be associated with operative mortality by multivariate logistic analysis. Only 50 (8.8%) IDs met all five factors related to better FTR rates. Conclusions The present findings indicate that several hospital factors surrounding surgical treatment, characterized by abundant human resources, are closely related to better postoperative recovery from severe complications.
Collapse
Affiliation(s)
- Itaru Endo
- The Japanese Society of Gastroenterological SurgeryTokyoJapan
- Department of Gastroenterological SurgeryYokohama City UniversityYokohamaJapan
| | - Arata Takahashi
- Department of Health Policy and Management, School of MedicineKeio UniversityTokyoJapan
| | | | - Hiroaki Miyata
- Department of Healthcare Quality Assessment, Graduate School of MedicineThe University of TokyoTokyoJapan
| | - Yuki Homma
- Department of Gastroenterological SurgeryYokohama City UniversityYokohamaJapan
| | - Takafumi Kumamoto
- Department of Gastroenterological SurgeryYokohama City UniversityYokohamaJapan
| | - Ryusei Matsuyama
- Department of Gastroenterological SurgeryYokohama City UniversityYokohamaJapan
| | | | - Yuko Kitagawa
- The Japanese Society of Gastroenterological SurgeryTokyoJapan
| | - Yasuyuki Seto
- The Japanese Society of Gastroenterological SurgeryTokyoJapan
- National Clinical DatabaseTokyoJapan
| |
Collapse
|
5
|
Fukamatsu F, Yamada K, Takekoshi D, Aonuma T, Oyama K, Yanagisawa S, Yamada A, Shimizu A, Fujinaga Y. Embolization using both n-butyl cyanoacrylate and gelatin sponges in a patient with a posterior superior pancreaticoduodenal artery pseudoaneurysm that ruptured and bled into the drain tube. Radiol Case Rep 2024; 19:876-880. [PMID: 38188963 PMCID: PMC10770504 DOI: 10.1016/j.radcr.2023.11.060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 11/22/2023] [Indexed: 01/09/2024] Open
Abstract
Transcatheter arterial embolization is a useful treatment for postpancreatectomy hemorrhage, a severe complication of pancreatic surgery. N-butyl cyanoacrylate is a liquid and permanent embolic material that is widely used in transcatheter arterial embolization. However, its use can lead to the adherence of the catheter to the vessel wall and occlusion of the catheter lumen. This case report presents the case of a 63-year-old man with a postpancreatectomy posterior superior pancreaticoduodenal artery pseudoaneurysm, which ruptured and bled into a drain tube. The patient underwent transcatheter arterial embolization using N-butyl cyanoacrylate and a gelatin sponge without the incidence of adherence or occlusion of the drain tube. Gelatin sponge, which was used as a temporary embolic material, was effective in preventing the drain tube from adhering and occluding.
Collapse
Affiliation(s)
- Fumiaki Fukamatsu
- Department of Radiology, Shinshu University School of Medicine,3-1-1 Asahi, Matsumoto, Nagano 390-8621, Japan
| | - Keiichi Yamada
- Department of Radiology, Shinshu University School of Medicine,3-1-1 Asahi, Matsumoto, Nagano 390-8621, Japan
| | - Daiya Takekoshi
- Department of Radiology, Shinshu University School of Medicine,3-1-1 Asahi, Matsumoto, Nagano 390-8621, Japan
| | - Takanori Aonuma
- Department of Radiology, Shinshu University School of Medicine,3-1-1 Asahi, Matsumoto, Nagano 390-8621, Japan
| | - Kazuki Oyama
- Department of Radiology, Shinshu University School of Medicine,3-1-1 Asahi, Matsumoto, Nagano 390-8621, Japan
| | - Shin Yanagisawa
- Department of Radiology, Shinshu University School of Medicine,3-1-1 Asahi, Matsumoto, Nagano 390-8621, Japan
| | - Akira Yamada
- Department of Radiology, Shinshu University School of Medicine,3-1-1 Asahi, Matsumoto, Nagano 390-8621, Japan
| | - Akira Shimizu
- Division of Gastroenterological, Hepato-Biliary-Pancreatic, Transplantation, and Pediatric Surgery, Department of Surgery, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano 390-8621, Japan
| | - Yasunari Fujinaga
- Department of Radiology, Shinshu University School of Medicine,3-1-1 Asahi, Matsumoto, Nagano 390-8621, Japan
| |
Collapse
|
6
|
Tan W, Yuan K, Ji K, Xiang T, Xin H, Li X, Zhang W, Song Z, Wang M, Duan F. Targeted versus Empiric Embolization for Delayed Postpancreatectomy Hemorrhage: A Retrospective Study of 312 Patients. J Vasc Interv Radiol 2024; 35:241-250.e1. [PMID: 37926344 DOI: 10.1016/j.jvir.2023.10.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 09/22/2023] [Accepted: 10/27/2023] [Indexed: 11/07/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Wenle Tan
- Department of Interventional Radiology, Chinese PLA General Hospital, Beijing, People's Republic of China
| | - Kai Yuan
- Department of Interventional Radiology, Chinese PLA General Hospital, Beijing, People's Republic of China
| | - Kan Ji
- Department of Interventional Radiology, Chinese PLA General Hospital, Beijing, People's Republic of China
| | - Tao Xiang
- Department of Interventional Radiology, Chinese PLA General Hospital, Beijing, People's Republic of China
| | - Hainan Xin
- Department of Interventional Radiology, Chinese PLA General Hospital, Beijing, People's Republic of China
| | - Xiaohui Li
- Department of Interventional Radiology, Chinese PLA General Hospital, Beijing, People's Republic of China
| | - Wenhe Zhang
- Department of Interventional Radiology, Chinese PLA General Hospital, Beijing, People's Republic of China
| | - Zhenfei Song
- Department of Interventional Radiology, Chinese PLA General Hospital, Beijing, People's Republic of China
| | - Maoqiang Wang
- Department of Interventional Radiology, Chinese PLA General Hospital, Beijing, People's Republic of China
| | - Feng Duan
- Department of Interventional Radiology, Chinese PLA General Hospital, Beijing, People's Republic of China.
| |
Collapse
|
7
|
Ikuta S, Fujikawa M, Nakajima T, Kasai M, Aihara T, Yamanaka N. Machine learning approach to predict postpancreatectomy hemorrhage following pancreaticoduodenectomy: a retrospective study. Langenbecks Arch Surg 2024; 409:29. [PMID: 38183456 DOI: 10.1007/s00423-023-03223-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 12/29/2023] [Indexed: 01/08/2024]
Abstract
BACKGROUND Postpancreatectomy hemorrhage (PPH) is a rare yet dreaded complication following pancreaticoduodenectomy (PD). This retrospective study aimed to explore a machine learning (ML) model for predicting PPH in PD patients. METHODS A total of 284 patients who underwent open PD at our institute were included in the analysis. To address the issue of imbalanced data, the adaptive synthetic sampling (ADASYN) technique was employed. The best-performing ML model was selected using the PyCaret library in Python and evaluated based on recall, precision, and F1 score metrics. In addition to assessing the model's performance on the test data, bootstrap validation (n = 1000) with the original dataset was conducted. RESULTS PPH occurred in 11 patients (3.9%), with a median onset time of 22 days postoperatively. These minority cases were oversampled to 85 using ADASYN. The extra trees classifier demonstrated superior performance with recall, precision, and F1 score of 0.967, 0.914, and 0.937, respectively. Both validation using the test data and bootstrap resampling consistently demonstrated recall, precision, and F1 score exceeding 0.9. The model identified the peak value of C-reactive protein during the first 7 postoperative days as the most significant feature, followed by the preoperative neutrophil-to-lymphocyte ratio. CONCLUSIONS This study highlights the potential of the ML approach to predict PPH occurrence following PD. Vigilance and early interventions guided by such model predictions could positively impact outcomes for high-risk patients.
Collapse
Affiliation(s)
- Shinichi Ikuta
- Department of Surgery, Meiwa Hospital, 4-31 Agenaruo, Nishinomiya, Hyogo, 663-8186, Japan.
| | - Masataka Fujikawa
- Department of Surgery, Meiwa Hospital, 4-31 Agenaruo, Nishinomiya, Hyogo, 663-8186, Japan
| | - Takayoshi Nakajima
- Department of Surgery, Meiwa Hospital, 4-31 Agenaruo, Nishinomiya, Hyogo, 663-8186, Japan
| | - Meidai Kasai
- Department of Surgery, Meiwa Hospital, 4-31 Agenaruo, Nishinomiya, Hyogo, 663-8186, Japan
| | - Tsukasa Aihara
- Department of Surgery, Meiwa Hospital, 4-31 Agenaruo, Nishinomiya, Hyogo, 663-8186, Japan
| | - Naoki Yamanaka
- Department of Surgery, Meiwa Hospital, 4-31 Agenaruo, Nishinomiya, Hyogo, 663-8186, Japan
| |
Collapse
|
8
|
Torres-Ruiz TA, Wharry L, Simo KA. Marginal Ulcer Following Completion Pancreatectomy Complicated by Portal Vein Erosion. Am Surg 2023; 89:6334-6337. [PMID: 37144793 DOI: 10.1177/00031348231175137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
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.
Collapse
Affiliation(s)
- Tania A Torres-Ruiz
- Department of Surgery, University of Toledo, Toledo, OH, USA
- Department of Surgery, Toledo Hospital, Promedica Health System, Toledo, OH, USA
| | - Laura Wharry
- Department of Surgery, University of Toledo, Toledo, OH, USA
- Department of Surgery, Toledo Hospital, Promedica Health System, Toledo, OH, USA
| | - Kerri A Simo
- Department of Surgery, University of Toledo, Toledo, OH, USA
- Department of Surgery, Toledo Hospital, Promedica Health System, Toledo, OH, USA
| |
Collapse
|
9
|
Izumi H, Yoshii H, Fujino R, Takeo S, Nomura E, Mukai M, Suda S, Tomita K, Kamei S, Ogawa Y, Hasebe T, Makuuchi H. Endovascular treatment of postoperative hemorrhage after pancreatectomy: a retrospective study. BMC Gastroenterol 2023; 23:379. [PMID: 37936060 PMCID: PMC10631063 DOI: 10.1186/s12876-023-03022-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 10/30/2023] [Indexed: 11/09/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Hideki Izumi
- Department of Gastrointestinal Surgery, Tokai University Hachioji Hospital, Ishikawa, Hachioji, Tokyo, 1838, 192-0032, Japan.
| | - Hisamichi Yoshii
- Department of Gastrointestinal Surgery, Tokai University Hachioji Hospital, Ishikawa, Hachioji, Tokyo, 1838, 192-0032, Japan
| | - Rika Fujino
- Department of Gastrointestinal Surgery, Tokai University Hachioji Hospital, Ishikawa, Hachioji, Tokyo, 1838, 192-0032, Japan
| | - Shigeya Takeo
- Department of Gastrointestinal Surgery, Tokai University Hachioji Hospital, Ishikawa, Hachioji, Tokyo, 1838, 192-0032, Japan
| | - Eiji Nomura
- Department of Gastrointestinal Surgery, Tokai University Hachioji Hospital, Ishikawa, Hachioji, Tokyo, 1838, 192-0032, Japan
| | - Masaya Mukai
- Department of Gastrointestinal Surgery, Tokai University Hachioji Hospital, Ishikawa, Hachioji, Tokyo, 1838, 192-0032, Japan
| | - Satoshi Suda
- Department of Radiology, Tokai University Hachioji Hospital, 1838 Ishikawa, Hachioji, Tokyo, 192-0032, Japan
| | - Kosuke Tomita
- Department of Radiology, Tokai University Hachioji Hospital, 1838 Ishikawa, Hachioji, Tokyo, 192-0032, Japan
| | - Shunsuke Kamei
- Department of Radiology, Tokai University Hachioji Hospital, 1838 Ishikawa, Hachioji, Tokyo, 192-0032, Japan
| | - Yukihisa Ogawa
- Department of Radiology, Tokai University Hachioji Hospital, 1838 Ishikawa, Hachioji, Tokyo, 192-0032, Japan
| | - Terumitsu Hasebe
- Department of Radiology, Tokai University Hachioji Hospital, 1838 Ishikawa, Hachioji, Tokyo, 192-0032, Japan
| | - Hiroyasu Makuuchi
- Department of Gastrointestinal Surgery, Tokai University Hachioji Hospital, Ishikawa, Hachioji, Tokyo, 1838, 192-0032, Japan
| |
Collapse
|
10
|
Ryou SH, Bang KB. Endoscopic management of postoperative bleeding. Clin Endosc 2023; 56:706-715. [PMID: 37915192 PMCID: PMC10665615 DOI: 10.5946/ce.2023.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 05/30/2023] [Accepted: 06/12/2023] [Indexed: 11/03/2023] Open
Abstract
Postoperative gastrointestinal bleeding is a rare but serious complication that can lead to prolonged hospitalization and significant morbidity and mortality. It can be managed by reoperation, endoscopy, or radiological intervention. Although reoperation carries risks, particularly in critically ill postoperative patients, minimally invasive interventions, such as endoscopy or radiological intervention, confer advantages. Endoscopy allows localization of the bleeding focus and hemostatic management at the same time. Although there have been concerns regarding the potential risk of creating an anastomotic disruption or perforation during early postoperative endoscopy, endoscopic management has become more popular over time. However, there is currently no consensus on the best endoscopic management for postoperative gastrointestinal bleeding because most practices are based on retrospective case series. Furthermore, there is a wide range of individual complexities in anatomical and clinical settings after surgery. This review focused on the safety and effectiveness of endoscopic management in various surgical settings.
Collapse
Affiliation(s)
- Sung Hyeok Ryou
- Department of Internal Medicine, Dankook University College of Medicine, Cheonan, Korea
| | - Ki Bae Bang
- Department of Internal Medicine, H+ Yangji Hospital, Seoul, Korea
| |
Collapse
|
11
|
Yu Z, Wu X, Zhou X, Hu X, Lu J, Fang S, Wang L, Ruan Y, Lu Y, Li H. Ligamentum teres hepatis wrapping of the gastroduodenal artery stump for protection in total laparoscopic pancreaticoduodenectomy: a single-center experience. J Int Med Res 2023; 51:3000605231188288. [PMID: 37548354 PMCID: PMC10408334 DOI: 10.1177/03000605231188288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 06/29/2023] [Indexed: 08/08/2023] Open
Abstract
OBJECTIVE Hemorrhage from the stump of the gastroduodenal artery (GDA) is a significant postoperative risk with pancreaticoduodenectomy (PD). Studies have shown that wrapping the GDA stump using the omentum or the falciform ligament can help prevent bleeding. We aimed to determine whether wrapping the GDA stump with the ligamentum teres hepatis (LTH) would reduce postoperative PD hemorrhage. METHODS We retrospectively reviewed data for 148 patients who underwent laparoscopic pancreatoduodenectomy (LPD) at our hospital from November 2015 to September 2021. We compared perioperative data from 63 LPD patients without wrapping of the GDA (unwrapped group) and 85 whose GDA stumps were wrapped (wrapped group). RESULTS There were no significant differences in the groups' baseline characteristics. The postoperative GDA stump bleeding incidence was significantly lower in the wrapped group than that in the unwrapped group (7.9% vs. 0, respectively). There was also no significant difference in the incidence of other complications (intra-abdominal infection, postoperative pancreatic fistula (POPF), biliary fistula, and gastrointestinal bleeding). CONCLUSION Using the LTH to wrap the GDA stump during LPD can reduce bleeding from the GDA stump but not the incidence of other complications.
Collapse
Affiliation(s)
- Zongdong Yu
- Department of Hepatobiliary and Pancreatic Surgery, Affiliated Li Huili Hospital, Ningbo University, Ningbo, China
- Health Science Center, Ningbo University, , Ningbo, China
| | - Xiang Wu
- Department of Hepatobiliary and Pancreatic Surgery, Affiliated Li Huili Hospital, Ningbo University, Ningbo, China
- Health Science Center, Ningbo University, , Ningbo, China
| | - Xinhua Zhou
- Department of Hepatobiliary and Pancreatic Surgery, Affiliated Li Huili Hospital, Ningbo University, Ningbo, China
| | - Xiaodong Hu
- Health Science Center, Ningbo University, , Ningbo, China
| | - Jun Lu
- Department of Hepatobiliary and Pancreatic Surgery, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Shenzhe Fang
- Department of Hepatobiliary and Pancreatic Surgery, Affiliated Li Huili Hospital, Ningbo University, Ningbo, China
- Health Science Center, Ningbo University, , Ningbo, China
| | - Luoluo Wang
- Department of Hepatobiliary and Pancreatic Surgery, Affiliated Li Huili Hospital, Ningbo University, Ningbo, China
| | - Yi Ruan
- Department of Hepatobiliary and Pancreatic Surgery, Affiliated Li Huili Hospital, Ningbo University, Ningbo, China
| | - Yeting Lu
- Department of Hepatobiliary and Pancreatic Surgery, Affiliated Li Huili Hospital, Ningbo University, Ningbo, China
| | - Hong Li
- Department of Hepatobiliary and Pancreatic Surgery, Affiliated Li Huili Hospital, Ningbo University, Ningbo, China
| |
Collapse
|
12
|
Stitzel HJ, Hue JJ, Elshami M, McCaulley L, Hoehn RS, Rothermel LD, Ammori JB, Hardacre JM, Winter JM, Ocuin LM. Assessing the use of Extended Venous Thromboembolism Prophylaxis on the Rates of Venous Thromboembolism and Postpancreatectomy Hemorrhage Following Pancreatectomy for Malignancy. Ann Surg 2023; 278:e80-e86. [PMID: 35797622 DOI: 10.1097/sla.0000000000005483] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To compare rates of venous thromboembolism (VTE) and postpancreatectomy hemorrhage (PPH) in patients with pancreatic or periampullary malignancy preimplementation and postimplementation of routine extended VTE prophylaxis. BACKGROUND Guidelines recommend up to 28 days of VTE prophylaxis following major abdominal cancer operations. There is a paucity of data examining rates of VTE and PPH in patients who receive extended VTE prophylaxis following pancreatectomy. METHODS Single-institution analysis of patients who underwent pancreatectomy for malignancy (2004-2021). VTE and PPH rates within 90 days of discharge were compared based on receipt of extended VTE prophylaxis with enoxaparin. RESULTS A total of 478 patients were included. Twenty-two (4.6%) patients developed a postoperative VTE, 12 (2.5%) of which occurred postdischarge. Twenty-five (5.2%) patients experienced PPH, 13 (2.7%) of which occurred postdischarge. There was no associated difference in the development of postdischarge VTE between patients who received extended VTE prophylaxis and those who did not (2.3% vs 2.8%, P =0.99). There was no associated difference in the rate of postdischarge PPH between patients who received extended VTE prophylaxis and those who did not (3.4% vs 1.9%, P =0.43). In the subset of patients on antiplatelet agents, the addition of enoxaparin did not appear to be associated with higher VTE (3.9 vs. 0%, P =0.31) or PPH (3.0 vs. 4.5%, P =0.64) rates. CONCLUSIONS Extended VTE prophylaxis following pancreatectomy for malignancy was not associated with differences in postdischarge VTE and PPH rates. These data suggest extended VTE prophylaxis is safe but may not be necessary for all patients following pancreatectomy.
Collapse
Affiliation(s)
- Henry J Stitzel
- Case Western Reserve University School of Medicine, Cleveland, OH
| | - Jonathan J Hue
- Division of Surgical Oncology, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Mohamedraed Elshami
- Division of Surgical Oncology, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Lauren McCaulley
- Division of Surgical Oncology, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Richard S Hoehn
- Division of Surgical Oncology, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Luke D Rothermel
- Division of Surgical Oncology, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - John B Ammori
- Division of Surgical Oncology, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Jeffrey M Hardacre
- Division of Surgical Oncology, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Jordan M Winter
- Division of Surgical Oncology, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Lee M Ocuin
- Division of Surgical Oncology, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH
| |
Collapse
|
13
|
Pang T, Wu Z, Zeng H, Zhang X, Hu M, Cao L. Analysis of the risk factors for secondary hemorrhage after abdominal surgery. Front Surg 2023; 10:1091162. [PMID: 37346762 PMCID: PMC10279872 DOI: 10.3389/fsurg.2023.1091162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Accepted: 02/24/2023] [Indexed: 06/23/2023] Open
Abstract
Introduction This study aimed to conduct a clinical review and analysis to recommend options for the prevention and treatment of postoperative hemorrhage. Patients and Methods A total of 138 patients who experienced postoperative hemorrhage after abdominal surgery in the period between January 2015 and December 2020 at the Sir Run Run Shaw Hospital, affiliated to Zhejiang University School of Medicine, participated in this study. They were divided into a group with primary bleeding only and a secondary bleeding group. Univariate and multivariate statistical analyses were performed, followed by plotting of cumulative hazard and survival curves for the two groups. Results The main factors of interest found to be associated with secondary hemorrhage were duration of the operation, the time of the first bleeding incident, intervention time, performance of combined organ resection, use of surgical intervention, occurrence of abdominal infection, admission to the intensive care unit (ICU), postoperative length of stay, and total hospitalization expenses. Among these, a long operative duration (>5 h) and an extended intervention time (>5 h) were identified as independent predictors of risk of secondary hemorrhage. Conclusions Secondary hemorrhage after abdominal surgery is mainly associated with subjective human factors, and it is an important cause of poor prognosis and even death. Proper reductions in operation time and implementation of a quick response to bleeding are the key factors in tackling bleeding. Further reduction in the rates of postoperative hemorrhage and mortality will require a concerted effort by surgeons in terms of both intraoperative surgical techniques and postoperative management.
Collapse
Affiliation(s)
- Tianshu Pang
- Department of General Surgery, School of Medicine, Sir RunRun Shaw Hospital, Zhejiang University, Hangzhou, China
| | - Zhengrong Wu
- Department of General Surgery, School of Medicine, Sir RunRun Shaw Hospital, Zhejiang University, Hangzhou, China
| | - Hongfen Zeng
- Department of Nursing, School of Medicine, Sir Run Run Shaw Hospital, Zhejiang University, Hangzhou, China
| | - Xiangyu Zhang
- Department of General Surgery, School of Medicine, Sir RunRun Shaw Hospital, Zhejiang University, Hangzhou, China
| | - Mengya Hu
- Department of Nursing, School of Medicine, Sir Run Run Shaw Hospital, Zhejiang University, Hangzhou, China
| | - Liping Cao
- Department of General Surgery, School of Medicine, Sir RunRun Shaw Hospital, Zhejiang University, Hangzhou, China
| |
Collapse
|
14
|
Rajendran J, Panwar R, Singh AN, Dash NR, Pal S, Srivastava DN, Sahni P, Madhusudhan KS. Management and outcomes of pseudoaneurysms presenting with late hemorrhage following pancreatic surgery: A six-year experience from a tertiary care center. Indian J Gastroenterol 2023; 42:361-369. [PMID: 37166698 DOI: 10.1007/s12664-023-01357-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 02/04/2023] [Indexed: 05/12/2023]
Abstract
BACKGROUND/PURPOSE Late hemorrhage following pancreatic surgery is associated with significant morbidity and mortality. Pseudoaneurysm (PSA) is an important source of late hemorrhage, which is effectively and safely managed by embolization. We aim to retrospectively review the outcomes of embolization for pseudoaneurysms causing late post-pancreatectomy hemorrhage over a period of six-years at our tertiary care center. METHODS Between 2014 and 2020, 616 pancreatic surgeries were performed and 25 patients had late hemorrhage (occurring > 24 hours post-operatively). The clinical parameters related to late hemorrhage, associated complications, embolization details, treatment success and their short-and long-term outcomes were analyzed. RESULTS Sixteen of 25 patients had PSA on digital subtraction angiography. Embolization was performed in these patients with technical and clinical success rates of 94.1% and 100%, respectively. Compared to patients without PSA, patients with PSA had significant hemoglobin drop (2.5 g/dL vs. 1.5 g/dL, p = 0.01), higher incidence of sentinel bleed (50% vs. 11.1%, p = 0.05) and lower requirement for surgery for bleeding (0% vs. 44.4%, p = 0.02). Clincally relevant postoperative pancreatic fistula and bile leak were seen in 72% and 52% of patients, respectively. Eight of these embolized patients died due to sepsis. The long-term outcome was good, once the patients were discharged. CONCLUSION Late hemorrhage after pancreatic surgery was associated with high mortality due to complications such as pancreatic fistula and bile leak. Sentinel bleeding was an important clinical indicator of PSA. Angiographic embolization is safe and effective without any adverse short or long-term outcomes.
Collapse
Affiliation(s)
- Jayapal Rajendran
- Department of Gastrointestinal Surgery, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India
| | - Rajesh Panwar
- Department of Gastrointestinal Surgery, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India
| | - Anand Narayan Singh
- Department of Gastrointestinal Surgery, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India
| | - Nihar Ranjan Dash
- Department of Gastrointestinal Surgery, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India
| | - Sujoy Pal
- Department of Gastrointestinal Surgery, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India
| | - Deep Narayan Srivastava
- Department of Radiodiagnosis and Interventional Radiology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India
| | - Peush Sahni
- Department of Gastrointestinal Surgery, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India
| | - Kumble Seetharama Madhusudhan
- Department of Radiodiagnosis and Interventional Radiology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India.
| |
Collapse
|
15
|
Guilbaud T, Faust C, Picaud O, Baumstarck K, Vicenty T, Farvacque G, Vanbrugghe C, Berdah S, Moutardier V, Birnbaum DJ. The falciform/round ligament "flooring," an effective method to reduce life-threatening post-pancreatectomy hemorrhage occurrence. Langenbecks Arch Surg 2023; 408:192. [PMID: 37171647 DOI: 10.1007/s00423-023-02915-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Accepted: 04/26/2023] [Indexed: 05/13/2023]
Abstract
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.
Collapse
Affiliation(s)
- Théophile Guilbaud
- Department of Digestive Surgery, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Aix-Marseille Université, Chemin Des Bourrely, 13015, Marseille, France
| | - Cindy Faust
- Center of Epidemiology and Health Economy, Direction de La Recherche en Santé, Assistance Publique-Hôpitaux de Marseille, Aix-Marseille University, Marseille, France
| | - Olivier Picaud
- Department of Digestive Surgery, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Aix-Marseille Université, Chemin Des Bourrely, 13015, Marseille, France
| | - Karine Baumstarck
- Center of Epidemiology and Health Economy, Direction de La Recherche en Santé, Assistance Publique-Hôpitaux de Marseille, Aix-Marseille University, Marseille, France
| | - Thibaud Vicenty
- Department of Digestive Surgery, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Aix-Marseille Université, Chemin Des Bourrely, 13015, Marseille, France
| | - Georges Farvacque
- Department of Digestive Surgery, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Aix-Marseille Université, Chemin Des Bourrely, 13015, Marseille, France
| | - Charles Vanbrugghe
- Department of Digestive Surgery, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Aix-Marseille Université, Chemin Des Bourrely, 13015, Marseille, France
| | - Stéphane Berdah
- Department of Digestive Surgery, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Aix-Marseille Université, Chemin Des Bourrely, 13015, Marseille, France
| | - Vincent Moutardier
- Department of Digestive Surgery, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Aix-Marseille Université, Chemin Des Bourrely, 13015, Marseille, France
| | - David Jérémie Birnbaum
- Department of Digestive Surgery, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Aix-Marseille Université, Chemin Des Bourrely, 13015, Marseille, France.
| |
Collapse
|
16
|
Thobie A, Robin F, Menahem B, Lubrano J, Boudjema K, Alves A, Dejardin O, Sulpice L. Influence of Hemorrhagic Complications of Pancreatoduodenectomy in Patients with Cancer on Short- and Long-Term Mortality. J Clin Med 2023; 12:jcm12082852. [PMID: 37109189 PMCID: PMC10143756 DOI: 10.3390/jcm12082852] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 03/27/2023] [Accepted: 04/07/2023] [Indexed: 04/29/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Alexandre Thobie
- Department of Digestive Surgery, University Hospital of Caen, CS 30001, CEDEX 9, 14033 Caen, France
- "ANTICIPE" U1086 INSERM, Team Ligue Contre le Cancer, Centre François Baclesse, University of Caen Normandy, 14000 Caen, France
| | - Fabien Robin
- Department of Digestive Surgery, University Hospital of Rennes, 35000 Rennes, France
| | - Benjamin Menahem
- Department of Digestive Surgery, University Hospital of Caen, CS 30001, CEDEX 9, 14033 Caen, France
- "ANTICIPE" U1086 INSERM, Team Ligue Contre le Cancer, Centre François Baclesse, University of Caen Normandy, 14000 Caen, France
| | - Jean Lubrano
- Department of Digestive Surgery, University Hospital of Caen, CS 30001, CEDEX 9, 14033 Caen, France
| | - Karim Boudjema
- Department of Digestive Surgery, University Hospital of Rennes, 35000 Rennes, France
| | - Arnaud Alves
- Department of Digestive Surgery, University Hospital of Caen, CS 30001, CEDEX 9, 14033 Caen, France
- "ANTICIPE" U1086 INSERM, Team Ligue Contre le Cancer, Centre François Baclesse, University of Caen Normandy, 14000 Caen, France
| | - Olivier Dejardin
- "ANTICIPE" U1086 INSERM, Team Ligue Contre le Cancer, Centre François Baclesse, University of Caen Normandy, 14000 Caen, France
- Department of Clinical Research, University Hospital of Caen, 14000 Caen, France
| | - Laurent Sulpice
- Department of Digestive Surgery, University Hospital of Rennes, 35000 Rennes, France
| |
Collapse
|
17
|
Kobayashi K, Inoue Y, Omiya K, Sato S, Kato T, Oba A, Ono Y, Sato T, Ito H, Matsueda K, Saiura A, Takahashi Y. Diagnosis and management of postpancreatectomy hemorrhage: A single-center experience of consecutive 1,096 pancreatoduodenectomies. Pancreatology 2023; 23:235-244. [PMID: 36764874 DOI: 10.1016/j.pan.2023.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 12/19/2022] [Accepted: 01/10/2023] [Indexed: 02/12/2023]
Abstract
BACKGROUND/OBJECTIVES This study aimed to assess the outcomes and characteristics of post-pancreatectomy hemorrhage (PPH) in over 1000 patients who underwent pancreatoduodenectomy (PD) at a high-volume hepatopancreaticobiliary center. METHODS This retrospective study analyzed consecutive patients who underwent PD from 2010 through 2021. PPH was diagnosed and managed using our algorithm based on timing of onset and location of hemorrhage. RESULTS Of 1096 patients who underwent PD, 33 patients (3.0%) had PPH; incidence of in-hospital and 90-day mortality relevant to PPH were one patient (3.0%) and zero patients, respectively. Early (≤24 h after surgery) and late (>24 h) PPH affected 9 patients and 24 patients, respectively; 16 patients experienced late-extraluminal PPH. The incidence of postoperative pancreatic fistula (p < 0.001), abdominal infection (p < 0.001), highest values of drain fluid amylase (DFA) within 3 days, and highest value of C-reactive protein (CRP) within 3 days after surgery (DFA: p < 0.001) (CRP: p = 0.010) were significantly higher in the late-extraluminal-PPH group. The highest values of DFA≥10000U/l (p = 0.022), CRP≥15 mg/dl (p < 0.001), and incidence of abdominal infection (p = 0.004) were identified as independent risk factors for PPH in the multivariate analysis. Although the hospital stay was significantly longer in the late-extraluminal-PPH group (p < 0.001), discharge to patient's home (p = 0.751) and readmission rate within 30-day (p = 0.765) and 90-day (p = 0.062) did not differ between groups. CONCLUSIONS Standardized management of PPH according to the onset and source of hemorrhage minimizes the incidence of serious deterioration and mortality. High-risk patients with PPH can be predicted based on the DFA values, CRP levels, and incidence of abdominal infections.
Collapse
Affiliation(s)
- Kosuke Kobayashi
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan.
| | - Yosuke Inoue
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan.
| | - Kojiro Omiya
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Shoki Sato
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Tomotaka Kato
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Atsushi Oba
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Yoshihiro Ono
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Takafumi Sato
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Hiromichi Ito
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Kiyoshi Matsueda
- Department of Diagnostic Ultrasound, Interventional Radiology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Akio Saiura
- Department of Hepatobiliary and Pancreatic Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Yu Takahashi
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| |
Collapse
|
18
|
Kim JS, Lee TY, Kwak BJ, Lee JS, Kwon YK, Yoon YC. Arterial reinforcement following pancreatoduodenectomy: The solution to prevent delayed hemorrhage caused by postoperative pancreatic fistula. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2022. [PMID: 36458401 DOI: 10.1002/jhbp.1294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 11/25/2022] [Accepted: 11/28/2022] [Indexed: 12/03/2022]
Abstract
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.
Collapse
Affiliation(s)
- Ji Su Kim
- Division of Hepatobiliary, Pancreas, and Abdominal Organ Transplant, Department of Surgery, The Catholic University of Korea Incheon St. Mary's Hospital, Incheon, Republic of Korea
| | - Tae Yoon Lee
- Division of Hepatobiliary, Pancreas, and Abdominal Organ Transplant, Department of Surgery, The Catholic University of Korea Incheon St. Mary's Hospital, Incheon, Republic of Korea
| | - Bong Jun Kwak
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Jun Suh Lee
- Department of Surgery, Seoul National University, College of Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Yong Kyong Kwon
- Division of Hepatobiliary, Pancreas, and Abdominal Organ Transplant, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Young Chul Yoon
- Division of Hepatobiliary, Pancreas, and Abdominal Organ Transplant, Department of Surgery, The Catholic University of Korea Incheon St. Mary's Hospital, Incheon, Republic of Korea
| |
Collapse
|
19
|
Takata H, Hirakata A, Makino H, Yokoyama T, Furuki H, Mizutani S, Katsuno A, Taniai N, Yoshida H. Two synchronous pseudoaneurysms after bile duct resection for distal cholangiocarcinoma. Clin J Gastroenterol 2022; 15:1151-1157. [DOI: 10.1007/s12328-022-01711-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 09/26/2022] [Indexed: 11/27/2022]
|
20
|
Trehub Y, Vasiliev O, Malovanna A. Spontaneous cessation of postpancreatectomy hemorrhage in a patient with celiac artery stenosis. Radiol Case Rep 2022; 17:3142-3146. [PMID: 35801121 PMCID: PMC9253043 DOI: 10.1016/j.radcr.2022.05.066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 05/22/2022] [Accepted: 05/24/2022] [Indexed: 11/30/2022] Open
Abstract
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.
Collapse
|
21
|
Maccabe TA, Robertson HF, Skipworth J, Rees J, Roberts K, Pathak S. A systematic review of post-pancreatectomy haemorrhage management stratified according to ISGPS grading. HPB (Oxford) 2022; 24:1110-1118. [PMID: 35101359 DOI: 10.1016/j.hpb.2021.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 11/15/2021] [Accepted: 12/08/2021] [Indexed: 12/12/2022]
Abstract
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.
Collapse
Affiliation(s)
- Thomas A Maccabe
- Department of Hepatopancreatobiliary Surgery, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol UK.
| | - Harry F Robertson
- Department of Hepatopancreatobiliary Surgery, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol UK
| | - James Skipworth
- Department of Hepatopancreatobiliary Surgery, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol UK
| | - Jonathan Rees
- Department of Hepatopancreatobiliary Surgery, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol UK
| | - Keith Roberts
- Department of Hepatopancreatobiliary Surgery, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol UK; Department of Pancreatic Surgery, University Hospitals Birmingham, UK
| | - Samir Pathak
- Department of Hepatopancreatobiliary Surgery, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol UK
| |
Collapse
|
22
|
Alekyan BG, Varava AB, Gorin DS, Lusnikov VP. Experience of using stent grafts in the treatment of patients with arrosive bleeding after pancreatic surgery. КАРДИОВАСКУЛЯРНАЯ ТЕРАПИЯ И ПРОФИЛАКТИКА 2022. [DOI: 10.15829/1728-8800-2022-3257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Aim. To evaluate inhospital outcomes of endovascular treatment in patients who underwent endoprosthetic replacement of the culprit vessel due to arrosive bleeding after pancreatic surgery.Material and methods. In the period 2012-2021 at the A. V. Vishnevsky National Medical Research Center of Surgery, 821 operations on the pancreas due to tumors and complicated chronic pancreatitis were performed. Seventy-five (9,1%) patients developed postoperative arrosive bleeding. Stent grafts were used to stop bleeding in 14 (18,7%) of them. There were 9 men (64,3%) and 5 women (35,7%). The median age of patients was 60 years (men — 61 years, women — 59 years). Arrosive bleeding occurred after pancreaticoduodenal resection in 13 patients, while in one case — after distal pancreatic resection. In all 14 cases, postoperative bleeding was severe and classified as grade C according to the International Study Group for Pancreatic Surgery (ISGPS) classification.Results. There were following sources of bleeding: gastroduodenal artery — 4 (28,6%) patients, proximal hepatic arteries (right/left) — in 4 (28,6%) patients, proximal superior mesenteric artery — in 2 (14,3%), dorsal pancreatic artery — in 1 (7,1%), false aneurysm of proximal splenic artery — in 1 (7,1%), proximal common hepatic artery — in 2 (14,3%). In 10 (71,4%) patients, endoprosthetic replacement of the proximal segment of culprit artery was performed, while in 4 (28,6%) patients with arrosion of short gastroduodenal artery stump and false aneurysm, endoprosthesis replacement of the common hepatic artery was performed with a transition to the proper hepatic artery. The technical success of endovascular hemostasis (absence of contrast media extravasation) was achieved in 100% of cases. Three (21,4%) of 14 patients developed rebleeding from another arterial source. Inhospital mortality was 28,6% (n=4). The cause of deaths in 3 cases was the direct complications of endovascular hemostasis, while in one patient — progressive postoperative pancreatitis with the outcome in multiple organ failure.Conclusion. Endovascular hemostasis using a stent graft is an effective surgical method for the treatment of arrosive bleeding after pancreatic surgery. The intervention is associated with possible complications, the risk of which must be taken into account before the procedure. We consider arrosive bleeding from a defect in the main vessel (common/ proper/right or left hepatic arteries, superior mesenteric artery) as an indication for performing endoprosthetic replacement.
Collapse
Affiliation(s)
- B. G. Alekyan
- Vishnevsky National Medical Research Center of Surgery
| | - A. B. Varava
- Vishnevsky National Medical Research Center of Surgery
| | - D. S. Gorin
- Vishnevsky National Medical Research Center of Surgery
| | | |
Collapse
|
23
|
Maleva OV, Sosnina AS, Uchasova EG, Ivanov SV, Trubnikova OA, Barbarash OL. Factors for early postoperative cognitive impairment in patients after coronary bypass surgery and carotid endarterectomy. КАРДИОВАСКУЛЯРНАЯ ТЕРАПИЯ И ПРОФИЛАКТИКА 2022. [DOI: 10.15829/1728-8800-2022-3166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Aim. To determine the relationship between perioperative factors and cognitive function in patients after coronary bypass grafting (CABG) in combination with unilateral carotid endarterectomy (CE).Material and methods. We examined 56 men in the perioperative period with CABG combined with unilateral CE (mean age, 64,0±7,1 years). Cognitive assessment was performed before and 5-7 days after surgery with Status PF program. An advanced psychometric examination included an assessment of voluntary attention (Bourdon test), short-term memory (tests on memorizing 10 numbers, 10 words, and 10 syllables), neurodynamics (visual-motor reaction time, level of functional mobility of nervous processes, brain performance, as well as the number of errors in these tasks and missed positive signals). The concentration of neuron-specific enolase (NSE) and S100β protein in the blood serum of patients before surgery, 24 hours and 5-7 days after surgery was determined using enzyme immunoassay.Results. In the early postoperative period, an increase in reaction time (p=0,031) was accompanied by an increase in errors in this test (p=0,042) and a decrease in the number of memorized numbers (p=0,022). Twenty four hours and 5-7 days after surgery, there were no differences between the perioperative NSE level (p1-2-3>0.05). Twenty four hours after CABG surgery, the level of S100β protein increased by 9,0% (p=0,001), while regression of S100β protein to the preoperative level was observed 5-7 days after operation.Conclusion. A relationship was found between the CABG factor and the attention level (r=-0,518; p=0,031), functional mobility reaction time (r=0,476; p=0,041), and the number of errors (r=0,449; p=0,032). A correlation was found between the factor of neurochemical markers, the number of processed letters on the 1st minute of Bourdon test (r=-0,642; p=0,014), the total number of processed letters in Bourdon test (r=-0,617; p=0,017). The combined factor of perioperative period was associated with functional mobility reaction time (r=0,609; p=0,041), the number of processed letters at 4 min (r=-0,490; p=0,017), and the total number of processed letters in the Bourdon test (r=-0,334; p=0,006).
Collapse
Affiliation(s)
- O. V. Maleva
- Research Institute for Complex Issues of Cardiovascular Diseases
| | - A. S. Sosnina
- Research Institute for Complex Issues of Cardiovascular Diseases
| | - E. G. Uchasova
- Research Institute for Complex Issues of Cardiovascular Diseases
| | - S. V. Ivanov
- Research Institute for Complex Issues of Cardiovascular Diseases
| | - O. A. Trubnikova
- Research Institute for Complex Issues of Cardiovascular Diseases
| | - O. L. Barbarash
- Research Institute for Complex Issues of Cardiovascular Diseases
| |
Collapse
|
24
|
Sawamura S, Koike Y, Yamamoto T, Terauchi M, Koyama S, Utsunomiya D. The use of viabahn VBX stent-grafts for the treatment of extrahepatic portal vein hemorrhage. MINIM INVASIV THER 2022; 31:1066-1069. [DOI: 10.1080/13645706.2022.2056706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Shungo Sawamura
- Department of Radiology, Yokohama City University Hospital, Yokohama, Japan
| | - Yuya Koike
- Department of Interventional Radiology, Saiseikai Yokohama City Nanbu Hospital, Yokohama, Japan
| | - Toh Yamamoto
- Department of Radiology, Yokohama City University Hospital, Yokohama, Japan
| | - Miki Terauchi
- Department of Radiology, Yokohama City University Hospital, Yokohama, Japan
| | - Shingo Koyama
- Department of Radiology, Yokohama City University Hospital, Yokohama, Japan
| | - Daisuke Utsunomiya
- Department of Radiology, Yokohama City University Hospital, Yokohama, Japan
| |
Collapse
|
25
|
Evaluation of Open Surgical and Endovascular Treatment Options for Visceral Artery Erosions after Pancreatitis and Pancreatic Surgery. Curr Oncol 2022; 29:2472-2482. [PMID: 35448175 PMCID: PMC9025466 DOI: 10.3390/curroncol29040201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 03/26/2022] [Accepted: 03/29/2022] [Indexed: 11/17/2022] Open
Abstract
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.
Collapse
|
26
|
Vilhav C, Fagman JB, Holmberg E, Naredi P, Engström C. C-reactive protein identifies patients at risk of postpancreatectomy hemorrhage. Langenbecks Arch Surg 2022; 407:1949-1959. [PMID: 35306601 PMCID: PMC9399186 DOI: 10.1007/s00423-022-02440-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 01/13/2022] [Indexed: 11/29/2022]
Abstract
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.
Collapse
Affiliation(s)
- C Vilhav
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden.
| | - J B Fagman
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - E Holmberg
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - P Naredi
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - C Engström
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| |
Collapse
|
27
|
Ohta K, Shimohira M, Kawai T, Sawada Y, Nakayama K, Sagoh H, Tatsuta A, Shibamoto Y. Utilization of an Occlusion Balloon Catheter during Stent-Graft Placement to Treat Postsurgical Visceral Arterial Hemorrhage. J Vasc Interv Radiol 2022; 33:304-307. [PMID: 35221047 DOI: 10.1016/j.jvir.2021.11.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 11/03/2021] [Accepted: 11/25/2021] [Indexed: 11/18/2022] Open
Abstract
The utility of occluding the bleeding artery using an occlusion balloon catheter during stent-graft placement for visceral artery bleeding was evaluated. Stent-graft placement for visceral artery bleeding was performed using a balloon catheter in 6 patients. All bleeding occurred after biliary or pancreatic surgery. Since 1 patient underwent the procedure twice, 7 procedures were assessed in total. Technical success, procedure-related adverse events, and 30-day mortality rates were evaluated. Technical success was defined as the placement of the stent-graft at the target site and the resolution of extravasation or pseudoaneurysm. In all procedures, stent-graft placement was successfully performed (technical success rate, 100%). Focal liver infarction occurred in 2 of 7 patients (29%), but did not require further treatment and was considered a minor adverse event. The 30-day mortality rate was 0%. In conclusion, the use of an occlusion balloon in the feeding artery facilitated successful stent-graft repair of hemorrhage from visceral arteries.
Collapse
Affiliation(s)
- Kengo Ohta
- Department of Radiology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Masashi Shimohira
- Department of Radiology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan.
| | - Tatsuya Kawai
- Department of Radiology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Yusuke Sawada
- Department of Radiology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Keita Nakayama
- Department of Radiology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Haruna Sagoh
- Department of Radiology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Ayame Tatsuta
- Department of Radiology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Yuta Shibamoto
- Department of Radiology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| |
Collapse
|
28
|
Ono S, Yamazoe S, Takigawa Y, Hasegawa H. Percutaneous transhepatic coil and cover technique with small system for the extrahepatic portal vein hemorrhage after pancreaticoduodenectomy. Radiol Case Rep 2022; 17:1246-1250. [PMID: 35198086 PMCID: PMC8844650 DOI: 10.1016/j.radcr.2022.01.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 01/15/2022] [Indexed: 10/27/2022] Open
Abstract
Post-pancreaticoduodenectomy hemorrhage is a life-threatening complication that usually occurs in skeletonized arteries. Venous hemorrhage is a rarer complication, and surgical management is often challenging. We herein report the case of an 80-year-old man who suffered from prolonged pancreatic fistula and long-term drainage tube placement, which could cause late post-pancreaticoduodenectomy hemorrhage from the confluence of the splenic and extrahepatic portal veins. An intrahepatic posterior portal venous branch was percutaneously punctured, and the splenic vein was embolized using coils and a vascular plug. A balloon-expandable covered stent was also placed from the superior mesenteric vein to the main portal vein to cover the confluence, which required a system as small as 8-F. Portal venography revealed good patency without extravasation. Thereafter, antithrombotic and antibacterial treatments were successfully administered without any additional interventions. He remained well without any evidence of thrombosis or indolent infection 19 months after endovascular treatment. The endovascular coil and cover technique with prolonged adjuvant therapy is a feasible alternative for managing such critical situations.
Collapse
Affiliation(s)
- Shigeshi Ono
- Department of Surgery, Tokyo Dental College Ichikawa General Hospital, 5-11-13 Sugano, Ichikawa, Chiba, Japan.,Corresponding author.
| | - Shinji Yamazoe
- Department of Radiology, Tokyo Dental College Ichikawa General Hospital, Chiba, Japan
| | - Yutaka Takigawa
- Department of Surgery, Tokyo Dental College Ichikawa General Hospital, 5-11-13 Sugano, Ichikawa, Chiba, Japan
| | - Hirotoshi Hasegawa
- Department of Surgery, Tokyo Dental College Ichikawa General Hospital, 5-11-13 Sugano, Ichikawa, Chiba, Japan
| |
Collapse
|
29
|
Incidence and Contemporary Management of Delayed Bleeding Following Pancreaticoduodenectomy. World J Surg 2022; 46:1161-1171. [PMID: 35084554 DOI: 10.1007/s00268-022-06451-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/20/2021] [Indexed: 10/19/2022]
Abstract
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.
Collapse
|
30
|
Alekyan BG, Varava AB, Lusnikov VP, Davydenko PI, Chevina AA, Goev AA, Kriger AG, Revishvili AS. Endovascular treatment of delayed arterial bleeding after pancreatic surgery: single-center experience. Khirurgiia (Mosk) 2022:5-15. [PMID: 35289543 DOI: 10.17116/hirurgia20220315] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
OBJECTIVE To evaluate technical aspects and clinical results of transcatheter arterial embolization (TAE) for delayed postoperative arterial bleeding after pancreatic surgery. MATERIAL AND METHODS There were 821 pancreatectomies between 2012 and 2020. Delayed bleeding occurred in 106 (12.9%) patients; 74 patients were included in the study. Previous pancreatic head resection was carried out in 75.7% of cases, pancreatic body resection - in 17.6% of cases, pancreatic tail resection - in 6.8% of patients. Primary endpoint was technical success of TAE, secondary endpoints - complications after TAE, as well as recurrent bleeding after embolization. RESULTS Angiography of celiac-mesenteric arterial system was performed in 74 patients (91 procedures). The most common sources of bleeding were gastroduodenal and superior mesenteric arteries (35.7%), jejunal arteries (13.1%), common hepatic artery (11.9%). Combination of embolization agents was applied for TAE (metal coils and non-calibrated PVA particles, 48.6%). In 11 (14.9%) patients, we applied stent-grafts. Technical success rate was 100%. Recurrent bleeding occurred in 13 (17.6%) patients. In-hospital mortality was 12.2% (n=9). CONCLUSION TAE is an effective treatment procedure in patients with arrosive bleeding. This method is characterized by high technical efficiency and low in-hospital mortality, but it does not affect recurrence of bleeding.
Collapse
Affiliation(s)
- B G Alekyan
- Vishnevsky National Medical Research Center of Surgery, Moscow, Russia
| | - A B Varava
- Vishnevsky National Medical Research Center of Surgery, Moscow, Russia
| | - V P Lusnikov
- Vishnevsky National Medical Research Center of Surgery, Moscow, Russia
| | - P I Davydenko
- Vishnevsky National Medical Research Center of Surgery, Moscow, Russia
| | - A A Chevina
- Vishnevsky National Medical Research Center of Surgery, Moscow, Russia
| | - A A Goev
- Vishnevsky National Medical Research Center of Surgery, Moscow, Russia
| | - A G Kriger
- Vishnevsky National Medical Research Center of Surgery, Moscow, Russia
| | - A Sh Revishvili
- Vishnevsky National Medical Research Center of Surgery, Moscow, Russia
| |
Collapse
|
31
|
Lin YM, Lin EY, Tseng HS, Lee RC, Huang HE, Wang SE, Shyr YM, Liu CA. Preventive covered stent placement at the gastroduodenal artery stump in angiogram-negative sentinel hemorrhage after pancreaticoduodenectomy. Abdom Radiol (NY) 2021; 46:4995-5006. [PMID: 34037809 DOI: 10.1007/s00261-021-03123-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 05/03/2021] [Accepted: 05/11/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE To evaluate the clinical outcomes of preventive covered stent placement at the gastroduodenal artery stump in patients with angiogram-negative sentinel hemorrhage after pancreaticoduodenectomy. METHODS Between July 2006 and September 2018, patients undergoing computed tomography angiography or diagnostic angiography for sentinel hemorrhage after pancreaticoduodenectomy were retrospectively reviewed. Patients having angiogram-negative angiography and undergoing preventive covered stent placement or conservative treatment were included. Clinical outcomes, technique success, and complications were evaluated. RESULTS A total of 25 patients (mean age 62.5 years) were evaluated, including 15 patients underwent preventive covered stent placement at the gastroduodenal artery stump and 10 patients received conservative treatments. The clinical success rates were 50% (5/10) and 86.7% (13/15) for conservative treatments and covered stent groups, respectively (p = 0.07). In the conservative treatment group, delayed massive hemorrhage occurred in five patients, two of whom died of recurrent bleeding due to gastroduodenal artery pseudoaneurysm within 16 days, and two had intraluminal hemorrhage within 5 days. In the covered stent group, one patient had inferior pancreaticoduodenal artery pseudoaneurysm 1 day after the placement of the covered stent, and one had recurrent bleeding due to duodenal ulcer within 14 days. The 30-day mortality was 40% (4/10) and 0 in the conservative treatment and covered stent groups, respectively (p = 0.02). The difference in the overall survival was nonsignificant between the two groups (p = 0.23). CONCLUSIONS The preventive covered stent placement at the gastroduodenal artery stump is safe and reduces delayed massive hemorrhage and short-term mortality in patients with angiogram-negative sentinel hemorrhage after pancreaticoduodenectomy.
Collapse
|
32
|
Fujikawa T, Naito S. Safety of pancreatic surgery with special reference to antithrombotic therapy: A systematic review of the literature. World J Clin Cases 2021; 9:6747-6758. [PMID: 34447821 PMCID: PMC8362514 DOI: 10.12998/wjcc.v9.i23.6747] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 04/27/2021] [Accepted: 07/06/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Postpancreatectomy hemorrhage (PPH) is the most severe type of complication after pancreatic surgery, although the effect of antithrombotic therapy (ATT) on PPH is largely unknown. The safety and efficacy of chemical thromboprophylaxis for venous thromboembolism (VTE) remains controversial.
AIM To elucidate the effect of ATT on PPH.
METHODS Published articles between 2013 and 2020 were searched from PubMed and Google Scholar, and after careful reviewing of all studies, studies concerning ATT and pancreatic surgery were included. Data such as study design, type of surgical procedures, type of antithrombotic drugs, and surgical outcome were extracted from the studies.
RESULTS Nineteen published articles with a total of 37863 patients who underwent pancreatic surgery were included in the systematic review. Fourteen were cohort studies, with only three being prospective in nature. Two studies demonstrated that in patients receiving chronic ATT, which were mostly managed by heparin bridging, the risk of PPH was higher compared with those without ATT, and one study showed that patients with direct-acting oral anticoagulants managed by heparin bridging had significantly higher postoperative bleeding rates than others. The remaining six studies reported that pancreatic surgery can be safely performed in patients receiving chronic ATT, even under preoperative aspirin continuation. Concerning chemical thromboprophylaxis for VTE, most studies have shown a potentially high risk of PPH in patients undergoing chemical thromboprophylaxis; however, its effectiveness against VTE has not been statistically demonstrated, particularly among Asian patients.
CONCLUSION Pancreatic surgery in chronically ATT-received patients can be safely performed without an increase in the occurrence of PPH, although the safety and efficacy of chemical thromboprophylaxis for VTE during pancreatic surgery is still controversial. Further investigation using reliable studies with good design is required to establish definite protocols or guidelines.
Collapse
Affiliation(s)
- Takahisa Fujikawa
- Department of Surgery, Kokura Memorial Hospital, Kitakyushu 802-8555, Japan
| | - Shigetoshi Naito
- Department of Surgery, Kokura Memorial Hospital, Kitakyushu 802-8555, Japan
| |
Collapse
|
33
|
Alekyan BG, Lusnikov VP, Varava AB, Kriger AG. [Endovascular treatment of arterial bleeding after pancreatic surgery]. Khirurgiia (Mosk) 2021:76-83. [PMID: 34363449 DOI: 10.17116/hirurgia202108176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
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.
Collapse
Affiliation(s)
- B G Alekyan
- Vishnevsky National Medical Research Center of Surgery, Moscow, Russia
| | - V P Lusnikov
- Vishnevsky National Medical Research Center of Surgery, Moscow, Russia
| | - A B Varava
- Vishnevsky National Medical Research Center of Surgery, Moscow, Russia
| | - A G Kriger
- Vishnevsky National Medical Research Center of Surgery, Moscow, Russia
| |
Collapse
|
34
|
Bizzoca C, Fedele S, Lippolis AS, Aquilino F, Castellana M, Basile MR, Lucarelli G, Vincenti L. Modified Technique for Wirsung-Pancreatogastric Anastomosis after Pancreatoduodenectomy: A Single Center Experience and Systematic Review of the Literature. J Clin Med 2021; 10:3064. [PMID: 34300229 PMCID: PMC8303560 DOI: 10.3390/jcm10143064] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 06/03/2021] [Accepted: 07/06/2021] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND The mortality rate following pancreaticoduodenectomy (PD) has been decreasing over the past few years; nonetheless, the morbidity rate remains elevated. The most common complications after PD are post-operative pancreatic fistula (POPF) and delayed gastric emptying (DGE) syndrome. The issue as to which is the best reconstruction method for the treatment of the pancreatic remnant after PD is still a matter of debate. The aim of this study was to retrospectively analyze the morbidity rate in 100 consecutive PD reconstructed with Wirsung-Pancreato-Gastro-Anastomosis (WPGA), performed by a single surgeon applying a personal modification of the pancreatic reconstruction technique. METHODS During an 8-year period (May 2012 to March 2020), 100 consecutive patients underwent PD reconstructed with WPGA. The series included 57 males and 43 females (M/F 1.32), with a mean age of 68 (range 41-86) years. The 90-day morbidity and mortality were retrospectively analyzed. Additionally, a systematic review was conducted, comparing our technique with the existing literature on the topic. RESULTS We observed eight cases of clinically relevant POPF (8%), three cases of "primary" DGE (3%) and four patients suffering "secondary" DGE. The surgical morbidity and mortality rate were 26% and 6%, respectively. The median hospital stay was 13.6 days. The systematic review of the literature confirmed the originality of our modified technique for Wirsung-Pancreato-Gastro-Anastomosis. CONCLUSIONS Our modified double-layer WPGA is associated with a very low incidence of POPF and DGE. Also, the technique avoids the risk of acute hemorrhage of the pancreatic parenchyma.
Collapse
Affiliation(s)
- Cinzia Bizzoca
- Department of General Surgery “Ospedaliera”, Polyclinic Hospital of Bari, Piazza G. Cesare 11, 70124 Bari, Italy;
| | - Salvatore Fedele
- General Surgery Unit, National Institute of Gastroenterology Saverio de Bellis, Research Hospital, via Turi 27, Castellana Grotte, 70013 Bari, Italy; (S.F.); (F.A.)
| | - Anna Stella Lippolis
- Department of General Surgery, San Paolo Hospital, via Capo Scardicchio, 70123 Bari, Italy; (A.S.L.); (M.R.B.)
| | - Fabrizio Aquilino
- General Surgery Unit, National Institute of Gastroenterology Saverio de Bellis, Research Hospital, via Turi 27, Castellana Grotte, 70013 Bari, Italy; (S.F.); (F.A.)
| | - Marco Castellana
- Unit of Research Methodology and Data Sciences for Population Health, National Institute of Gastroenterology Saverio de Bellis, Research Hospital, via Turi 27, Castellana Grotte, 70013 Bari, Italy;
| | - Maria Raffaella Basile
- Department of General Surgery, San Paolo Hospital, via Capo Scardicchio, 70123 Bari, Italy; (A.S.L.); (M.R.B.)
| | - Giuseppe Lucarelli
- Andrology and Kidney Transplantation Unit, Department of Emergency and Organ Transplantation-Urology, University of Bari, 70124 Bari, Italy;
| | - Leonardo Vincenti
- Department of General Surgery “Ospedaliera”, Polyclinic Hospital of Bari, Piazza G. Cesare 11, 70124 Bari, Italy;
| |
Collapse
|
35
|
Delayed post-pancreatectomy hemorrhage and bleeding recurrence after percutaneous endovascular treatment: risk factors from a bi-centric study of 307 consecutive patients. Langenbecks Arch Surg 2021; 406:1893-1902. [PMID: 33758966 DOI: 10.1007/s00423-021-02146-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 03/03/2021] [Indexed: 01/08/2023]
Abstract
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.
Collapse
|
36
|
Finch LM, Baltatzis M, Byott S, Ganapathy AK, Kakani N, Lake E, Cadwallader R, Hazar C, Seriki D, Butterfield S, Jegatheeswaran S, Jamdar S, de Liguori Carino N, Siriwardena AK. Endovascular Hepatic Artery Stents in the Modern Management of Postpancreatectomy Hemorrhage. ANNALS OF SURGERY OPEN 2021; 2:e038. [PMID: 37638254 PMCID: PMC10455063 DOI: 10.1097/as9.0000000000000038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 01/08/2021] [Indexed: 11/26/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Louise M. Finch
- From the Regional Hepato-Pancreato-Biliary Surgery Unit, Manchester Royal Infirmary, Manchester, United Kingdom
| | - Minas Baltatzis
- From the Regional Hepato-Pancreato-Biliary Surgery Unit, Manchester Royal Infirmary, Manchester, United Kingdom
| | - Sam Byott
- Vascular Radiology Department, Manchester Royal Infirmary, Manchester, United Kingdom
| | | | - Nirmal Kakani
- Vascular Radiology Department, Manchester Royal Infirmary, Manchester, United Kingdom
| | - Edward Lake
- Vascular Radiology Department, Manchester Royal Infirmary, Manchester, United Kingdom
| | - Rosemary Cadwallader
- Vascular Radiology Department, Manchester Royal Infirmary, Manchester, United Kingdom
| | - Can Hazar
- Vascular Radiology Department, Manchester Royal Infirmary, Manchester, United Kingdom
| | - Dare Seriki
- Vascular Radiology Department, Manchester Royal Infirmary, Manchester, United Kingdom
| | - Stephen Butterfield
- Vascular Radiology Department, Manchester Royal Infirmary, Manchester, United Kingdom
| | - Santhalingam Jegatheeswaran
- From the Regional Hepato-Pancreato-Biliary Surgery Unit, Manchester Royal Infirmary, Manchester, United Kingdom
| | - Saurabh Jamdar
- From the Regional Hepato-Pancreato-Biliary Surgery Unit, Manchester Royal Infirmary, Manchester, United Kingdom
| | - Nicola de Liguori Carino
- From the Regional Hepato-Pancreato-Biliary Surgery Unit, Manchester Royal Infirmary, Manchester, United Kingdom
| | - Ajith K. Siriwardena
- From the Regional Hepato-Pancreato-Biliary Surgery Unit, Manchester Royal Infirmary, Manchester, United Kingdom
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| |
Collapse
|
37
|
Maehira H, Iida H, Mori H, Yasukawa D, Maekawa T, Muramoto K, Takebayashi K, Kaida S, Miyake T, Tani M. Superior perianastomotic fluid collection in the early postoperative period affects pseudoaneurysm occurrence after pancreaticoduodenectomy. Langenbecks Arch Surg 2021; 406:1461-1468. [PMID: 33389107 DOI: 10.1007/s00423-020-02072-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 12/22/2020] [Indexed: 11/29/2022]
Abstract
PURPOSE Pseudoaneurysm (PA) after pancreaticoduodenectomy (PD) is a harmful complication due to postoperative pancreatic fistula. However, the preventive method for PA is unclear. This study aimed to assess the risk factors for PA after PD and to evaluate the clinical features of patients with PA. METHODS Medical records of 54 patients who underwent PD and developed clinically relevant postoperative pancreatic fistula (POPF) were retrospectively reviewed. We evaluated postoperative computed tomography (CT) findings, including the perianastomotic fluid collection (PFC) location on postoperative day 4. Perioperative findings and postoperative CT findings were compared between patients with and without PA after PD. RESULTS The PA group included nine patients (17%). The median postoperative day of diagnosis of PA was 17 (range, 7-33). The PA locations were the gastroduodenal artery stump (n = 3), dorsal pancreatic artery (DPA) stump from the common hepatic artery (n = 4), DPA stump from the replaced right hepatic artery (n = 1), and inferior pancreaticoduodenal artery stump (n = 1). The prevalence of falciform ligament wrap to the hepatic artery was lower (33% vs. 78%, p = 0.014) and superior PFC prevalence was higher (100% vs. 58%, p = 0.019) in the PA group than in the non-PA group. Superior PFC reached the dorsal part of the caudate lobe of the liver in all patients with PA. Furthermore, all PAs occurred at the arteries that could not be wrapped by the falciform ligament. CONCLUSION Prevention of superior PFC and falciform ligament wrapping may reduce PA occurrence after PD with clinically relevant POPF.
Collapse
Affiliation(s)
- Hiromitsu Maehira
- Department of Surgery, Shiga University of Medical Science, Setatsukinowa-cho, Otsu, Shiga, 520-2192, Japan.
| | - Hiroya Iida
- Department of Surgery, Shiga University of Medical Science, Setatsukinowa-cho, Otsu, Shiga, 520-2192, Japan
| | - Haruki Mori
- Department of Surgery, Shiga University of Medical Science, Setatsukinowa-cho, Otsu, Shiga, 520-2192, Japan
| | - Daiki Yasukawa
- Department of Surgery, Shiga University of Medical Science, Setatsukinowa-cho, Otsu, Shiga, 520-2192, Japan
| | - Takeru Maekawa
- Department of Surgery, Shiga University of Medical Science, Setatsukinowa-cho, Otsu, Shiga, 520-2192, Japan
| | - Keiji Muramoto
- Department of Surgery, Shiga University of Medical Science, Setatsukinowa-cho, Otsu, Shiga, 520-2192, Japan
| | - Katsushi Takebayashi
- Department of Surgery, Shiga University of Medical Science, Setatsukinowa-cho, Otsu, Shiga, 520-2192, Japan
| | - Sachiko Kaida
- Department of Surgery, Shiga University of Medical Science, Setatsukinowa-cho, Otsu, Shiga, 520-2192, Japan
| | - Toru Miyake
- Department of Surgery, Shiga University of Medical Science, Setatsukinowa-cho, Otsu, Shiga, 520-2192, Japan
| | - Masaji Tani
- Department of Surgery, Shiga University of Medical Science, Setatsukinowa-cho, Otsu, Shiga, 520-2192, Japan
| |
Collapse
|
38
|
Sakai N, Yoshitomi H, Furukawa K, Takayashiki T, Kuboki S, Takano S, Suzuki D, Kagawa S, Mishima T, Nakadai E, Ohtsuka M. Outcome of interventional radiology for delayed postoperative hemorrhage in hepatobiliary and pancreatic surgery. J Gastroenterol Hepatol 2020; 35:2264-2272. [PMID: 32525234 DOI: 10.1111/jgh.15140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 06/02/2020] [Accepted: 06/06/2020] [Indexed: 12/09/2022]
Abstract
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.
Collapse
Affiliation(s)
- Nozomu Sakai
- Department of General Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Hideyuki Yoshitomi
- Department of General Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Katsunori Furukawa
- Department of General Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Tsukasa Takayashiki
- Department of General Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Satoshi Kuboki
- Department of General Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Shigetsugu Takano
- Department of General Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Daisuke Suzuki
- Department of General Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Shingo Kagawa
- Department of General Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Takashi Mishima
- Department of General Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Eri Nakadai
- Department of General Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Masayuki Ohtsuka
- Department of General Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| |
Collapse
|
39
|
Stephanie S, Willard M. 'Whippled to death: an uncommon case of fatal gastrointestinal bleeding'. J Community Hosp Intern Med Perspect 2020; 10:560-561. [PMID: 33194129 PMCID: PMC7599020 DOI: 10.1080/20009666.2020.1815462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Affiliation(s)
- Stephanie Stephanie
- Department of Medicine, Internal Medicine Resident University of Maryland School of Medicine-Midtown Campus, Baltimore, MD, USA
| | - Megan Willard
- Section of Gastroenterology and Hepatology, School of Medicine-Health Sciences, West Virginia University, West Virginia, USA
| |
Collapse
|
40
|
Wu Y, Dai J, Shen J, Zhang X, Peng W, Li C, Wen T. Complete embolisation of the proper hepatic artery for delayed haemorrhage after pancreaticoduodenectomy: a case report. J Int Med Res 2020; 48:300060520961216. [PMID: 33050769 PMCID: PMC7570303 DOI: 10.1177/0300060520961216] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Youwei Wu
- Department of Liver Surgery & Liver Transplantation Center, West China Hospital, Sichuan University, Chengdu, China
| | - Junlong Dai
- Department of Liver Surgery & Liver Transplantation Center, West China Hospital, Sichuan University, Chengdu, China
| | - Junyi Shen
- Department of Liver Surgery & Liver Transplantation Center, West China Hospital, Sichuan University, Chengdu, China
| | - Xiaoyun Zhang
- Department of Liver Surgery & Liver Transplantation Center, West China Hospital, Sichuan University, Chengdu, China
| | - Wei Peng
- Department of Liver Surgery & Liver Transplantation Center, West China Hospital, Sichuan University, Chengdu, China
| | - Chuan Li
- Department of Liver Surgery & Liver Transplantation Center, West China Hospital, Sichuan University, Chengdu, China
| | - Tianfu Wen
- Department of Liver Surgery & Liver Transplantation Center, West China Hospital, Sichuan University, Chengdu, China
| |
Collapse
|
41
|
Khuri S, Mansour S, Obeid A, Azzam A, Borzellino G, Kluger Y. Postpancreatoduodenectomy Hemorrhage: Association between the Causes and the Severity of the Bleeding. Visc Med 2020; 37:171-179. [PMID: 34250074 DOI: 10.1159/000509894] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 07/02/2020] [Indexed: 01/08/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Safi Khuri
- Department of General Surgery, Rambam Health Care Campus, Haifa, Israel.,HPB and Surgical Oncology Unit, Rambam Health Care Campus, Haifa, Israel
| | - Subhi Mansour
- Department of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Amir Obeid
- Department of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Ameer Azzam
- Emergency Medicine Department, Rambam Health Care Campus, Haifa, Israel
| | | | - Yoram Kluger
- Department of General Surgery, Rambam Health Care Campus, Haifa, Israel.,HPB and Surgical Oncology Unit, Rambam Health Care Campus, Haifa, Israel
| |
Collapse
|
42
|
Andreasi V, Partelli S, Crippa S, Balzano G, Tamburrino D, Muffatti F, Belfiori G, Cirocchi R, Falconi M. A systematic review and meta-analysis on the role of omental or falciform ligament wrapping during pancreaticoduodenectomy. HPB (Oxford) 2020; 22:1227-1239. [PMID: 32631806 DOI: 10.1016/j.hpb.2020.05.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 05/04/2020] [Accepted: 05/08/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND The role of wrapping in the setting of pancreaticoduodenectomy (PD) is controversial. This study aimed to assess whether the use of omental or falciform ligament wrapping of pancreatic anastomosis and/or vessels could reduce the rate of POPF and postpancreatectomy hemorrhage (PPH) after PD. METHODS Studies comparing PD with (PD-W) and without wrapping (PD-nW) were included. Primary outcomes were POPF and extraluminal PPH. Dichotomous variables were analyzed for risk ratios (RR) with 95% Confidence Intervals. RESULTS Nine studies involving 4384 patients were considered. The risk of POPF and clinically relevant POPF (CR-POPF) was similar between patients with and without omental wrapping of pancreatic anastomosis when considered as overall. A significant benefit from wrapping in terms of CR-POPF (RR 0.14, P = 0.002) was reported for patients who underwent PD with pancreaticojejunostomy (PJ). The risk of extraluminal PPH was slightly lower in patients who underwent vessels wrapping compared to those who did not (RR 0.58, P = 0.020). Similar extraluminal PPH rates were reported for patients with and without wrapping of pancreatic anastomosis (P = 0.620). DISCUSSION Data from low-evidence studies suggest that omental wrapping of PJ may reduce the incidence of CR-POPF, whereas vessels wrapping may have a slight effect for preventing extraluminal PPH.
Collapse
Affiliation(s)
- Valentina Andreasi
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Stefano Partelli
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Stefano Crippa
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Gianpaolo Balzano
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Domenico Tamburrino
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Francesca Muffatti
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giulio Belfiori
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Roberto Cirocchi
- Department of General Surgery and Surgical Oncology, University of Perugia, Hospital of Terni, Terni, Italy
| | - Massimo Falconi
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy.
| |
Collapse
|
43
|
Das S, Ray S, Mangla V, Mehrotra S, Lalwani S, Mehta NN, Yadav A, Nundy S. Post pancreaticoduodenectomy hemorrhage: A retrospective analysis of incidence, risk factors and outcome. Saudi J Gastroenterol 2020; 26:292421. [PMID: 32811797 PMCID: PMC8019141 DOI: 10.4103/sjg.sjg_145_20] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 05/24/2020] [Accepted: 07/04/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND The operative mortality after pancreaticoduodenectomy (PD) has declined but morbidity still remains considerable. Post pancreaticoduodenectomy hemorrhage (PPH) occurs in 3-13% of patients following PD. We studied the incidence and outcomes of patients with PPH after PD to determine the associated risk factors and effect on hospital stay. METHODS We retrospectively analyzed from a prospectively collected data of patients developing PPH following PD between January 2007 and May 2018. ISGPS definition and grading system were used. By using univariate and multivariate analyses, independent predictors of PPH were identified. RESULTS Of the 340 patients undergoing PD, PPH occurred in 39 patients (11.5%), of whom 5 (12.8%) had Grade A, 22 (56.4%) had Grade B and 12 (30.8%) had Grade C PPH. Six (15.4%) of the 39 patients with PPH died against an overall mortality in the study population of 16 out of 340 patients (4.7%), reflecting higher mortality (P = 0.019) in patients with PPH . The independent risk factors for PPH were a high pre-operative bilirubin (mean 4.7 vs. 7.4 mg/dl, P = 0.01) and INR (mean 1.2 vs. 1.72, P = 0.024), whereas it was closely followed by but, but not significantly associated with pre-operative biliary stent placement (P = 0.09). Pancreatico-jejunostomy (PJ) leak was seen in 20.7% in non-hemorrhage group vs. 41% in hemorrhage group (P = 0.008) and was an independent risk factor for PPH. CONCLUSION PPH occurred in 11.5% of patients and resulted in a mortality four times greater than those without a PPH. It occurred more frequently in patents with a high pre-operative serum bilirubin, INR, biliary stenting or those with a PJ leak.
Collapse
Affiliation(s)
- Subhashish Das
- Department of Surgical Gastroenterology, Sir Gangaram Hospital, New Delhi, India
| | - Samrat Ray
- Department of Surgical Gastroenterology, Sir Gangaram Hospital, New Delhi, India
| | - Vivek Mangla
- Department of Surgical Gastroenterology, Sir Gangaram Hospital, New Delhi, India
| | - Siddharth Mehrotra
- Department of Surgical Gastroenterology, Sir Gangaram Hospital, New Delhi, India
| | - Shailendra Lalwani
- Department of Surgical Gastroenterology, Sir Gangaram Hospital, New Delhi, India
| | - Naimish N. Mehta
- Department of Surgical Gastroenterology, Sir Gangaram Hospital, New Delhi, India
| | - Amitabh Yadav
- Department of Surgical Gastroenterology, Sir Gangaram Hospital, New Delhi, India
| | - Samiran Nundy
- Department of Surgical Gastroenterology, Sir Gangaram Hospital, New Delhi, India
| |
Collapse
|
44
|
Hwang K, Lee JH, Hwang DW, Song KB, Kwon J, Gwon DI, Shin JH, Kim SC. Clinical features and outcomes of endovascular treatment of latent pseudoaneurysmal bleeding after pancreaticoduodenectomy. ANZ J Surg 2020; 90:E148-E153. [PMID: 32767469 DOI: 10.1111/ans.16184] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Revised: 07/03/2020] [Accepted: 07/04/2020] [Indexed: 01/03/2023]
Abstract
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.
Collapse
Affiliation(s)
- Kyungyeon Hwang
- Department of Surgery, Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, South Korea
| | - Jae Hoon Lee
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Dae Wook Hwang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Ki Byung Song
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Jaewoo Kwon
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Dong Il Gwon
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Ji Hoon Shin
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Song Cheol Kim
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| |
Collapse
|
45
|
Muglia R, Lanza E, Poretti D, D'Antuono F, Gennaro N, Gavazzi F, Zerbi A, Chiti A, Pedicini V. Emergency endovascular treatments for delayed hemorrhage after pancreaticobiliary surgery: indications, outcomes, and follow-up of a retrospective cohort. Abdom Radiol (NY) 2020; 45:2593-2602. [PMID: 32172410 DOI: 10.1007/s00261-020-02480-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE To evaluate the outcomes of emergency endovascular treatments for delayed bleeding after pancreaticobiliary surgery. METHODS We retrospectively evaluated 21 patients (M:F = 13:8, median age = 64 years) undergoing 23 endovascular treatments, performed from 2010 to 2017 in a single center. Data collected were patient characteristics; surgery; pathology; incidence of postoperative pancreatic fistulas (POPF); bleeding signs on CT and angiography; damaged artery; endovascular tools used; technical and clinical success; intervals between surgery, endovascular treatment, and discharge; survival rates. RESULTS Sixteen patients had pancreatoduodenectomy, three hepaticojejunostomy, two distal pancreatectomy. Indications for surgery were mainly biliary (33%), pancreatic (19%), or duodenal (10%) malignancies. Seventeen patients had "grade C" POPF, three suffered a biliary leak, one had no POPF. Active bleeding was present in 17/23 CTs and in 22/23 angiographies, mostly from hepatic (43%), gastroduodenal (22%), and splenic (13%) arteries. The endovascular treatments were performed with coils (26%), glue (22%), stent-graft (22%), and their combinations (30%). Sixteen patients had a single endovascular treatment, one underwent a second embolization, three had subsequent surgery, one had repeat embolization followed by surgery. Relaparotomy rate was 19%. Median hospital stay was 37 days (range 12-75); median intervals among pancreaticobiliary surgery, endovascular treatment, and discharge were 21 (2-36) and 12 (8-47) days, respectively. We observed 4/21 intrahospital deaths (median: 31 days from endovascular treatment, 4-53); 1-year survival rate of discharged patients was 71%. CONCLUSIONS Endovascular treatment using embolization and/or stent-graft placement is a useful first-line intervention to halt postoperative hemorrhage after pancreaticobiliary surgery and decreases the need for urgent relaparotomy.
Collapse
Affiliation(s)
- Riccardo Muglia
- Training School in Radiology, Humanitas University, Via Rita Levi Montalcini 4, 20090, Pieve Emanuele, Milano, Italy.
| | - Ezio Lanza
- Department of Diagnostic and Interventional Radiology, Humanitas Research Hospital, Via A. Manzoni 56, 20089, Rozzano, Milano, Italy
| | - Dario Poretti
- Department of Diagnostic and Interventional Radiology, Humanitas Research Hospital, Via A. Manzoni 56, 20089, Rozzano, Milano, Italy
| | - Felice D'Antuono
- Department of Diagnostic and Interventional Radiology, Humanitas Research Hospital, Via A. Manzoni 56, 20089, Rozzano, Milano, Italy
| | - Nicolò Gennaro
- Training School in Radiology, Humanitas University, Via Rita Levi Montalcini 4, 20090, Pieve Emanuele, Milano, Italy
| | - Francesca Gavazzi
- Department of General Surgery, Humanitas Research Hospital, Via A. Manzoni 56, 20089, Rozzano, Milano, Italy
| | - Alessandro Zerbi
- Department of General Surgery, Humanitas Research Hospital, Via A. Manzoni 56, 20089, Rozzano, Milano, Italy
| | - Arturo Chiti
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090, Pieve Emanuele, Milano, Italy
| | - Vittorio Pedicini
- Department of Diagnostic and Interventional Radiology, Humanitas Research Hospital, Via A. Manzoni 56, 20089, Rozzano, Milano, Italy
| |
Collapse
|
46
|
Nakamura K, Sho M, Satoi S, Kosaka H, Akahori T, Nagai M, Nakagawa K, Takagi T, Yamamoto T, Yamaki S. Impact of Antithrombotic Agents on Postpancreatectomy Hemorrhage: Results from a Retrospective Multicenter Study. J Am Coll Surg 2020; 231:460-469.e1. [PMID: 32634474 DOI: 10.1016/j.jamcollsurg.2020.06.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 06/16/2020] [Accepted: 06/16/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND This retrospective multicenter study aimed to evaluate the risk of postpancreatectomy hemorrhage (PPH) in patients receiving antithrombotic agents (ATAs). PPH is the most severe complication after pancreatectomy. However, there is little known about the strength of the association between ATA use, PPH, and other clinical outcomes. STUDY DESIGN Between 2007 and 2016, 1,297 patients underwent pancreatectomy at 2 surgical centers. ATA use included aspirin, clopidogrel, ticlopidine, warfarin, direct oral anticoagulants, and intravenous unfractionated heparin. The ATA group was composed of 144 patients who were taking ATAs before surgery. RESULTS A total of 35 patients developed PPH. The patients in the ATA group showed higher frequency (8.3% vs 2.0%, p < 0.001) of PPH compared with the control group (n = 1,153). In multivariate analysis, ATA use was an independent adverse risk factor for PPH (odds ratio [OR] 3.58, 95% CI 1.29-9.91, p = 0.014). Stratification by preoperative ATA therapy revealed a significant risk of PPH Grade C in patients receiving combined AT therapy. The median onset of late hemorrhage (>24 hours post-surgery) in the ATA group was later than in the control group (17.5 vs 8.5 days, p = 0.032), and the incidence tended to be higher in patients who restarted ATAs postoperatively. CONCLUSIONS History of ATA use is a significant risk factor for PPH, and postoperative resumption of ATAs appears to be associated with an increased risk of PPH. Patients receiving combined antithrombotic therapy may be at particularly high risk for PPH.
Collapse
Affiliation(s)
- Kota Nakamura
- Departments of Surgery, Nara Medical University, Nara, Japan
| | - Masayuki Sho
- Departments of Surgery, Nara Medical University, Nara, Japan.
| | | | | | | | - Minako Nagai
- Departments of Surgery, Nara Medical University, Nara, Japan
| | - Kenji Nakagawa
- Departments of Surgery, Nara Medical University, Nara, Japan
| | - Tadataka Takagi
- Departments of Surgery, Nara Medical University, Nara, Japan
| | | | - So Yamaki
- Kansai Medical University, Osaka, Japan
| |
Collapse
|
47
|
Wu J, Zhang G, Yao X, Xiang Y, Lin R, Yang Y, Zhang X. Achilles'heel of laparoscopic pancreatectomy: reconstruction of the remnant pancreas. Expert Rev Gastroenterol Hepatol 2020; 14:527-537. [PMID: 32567383 DOI: 10.1080/17474124.2020.1775582] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Laparoscopic pancreatic reconstruction is a challenging procedure and is considered the Achilles' heel of laparoscopic pancreatectomy. Multiple techniques of laparoscopic pancreatic reconstruction have been reported, but the optimal technique remains unclear. AREAS COVERED This paper provides a brief introduction to the developmental status and major related complications of laparoscopic pancreatic reconstruction. We reviewed all published literature on the technology of laparoscopic pancreatic reconstruction within the last 5 years and herein discuss the advantages and disadvantages of different reconstruction methods. We also discuss several details of different reconstruction techniques in terms of their significance to the operation and complications. EXPERT OPINION No individual method of laparoscopic pancreatic reconstruction is considered optimal for all conditions. The reconstruction strategy should be based on the surgeon's proficiency with laparoscopic technology and the patient's individual risk factors. Personalized methods of pancreatic reconstruction may more effectively reduce morbidity and mortality.
Collapse
Affiliation(s)
- Jiacheng Wu
- Department of Hepatobiliary and Pancreatic Surgery, Second Hospital of Jilin University , 130041, Changchun, China, East Asia.,Jilin Engineering Laboratory for Translational Medicine of Hepatobiliary and Pancreatic Diseases , 130041, Changchun, China, East Asia
| | - Guofeng Zhang
- Department of Hepatobiliary and Pancreatic Surgery, Second Hospital of Jilin University , 130041, Changchun, China, East Asia
| | - Xiaoxiao Yao
- Department of Hepatobiliary and Pancreatic Surgery, Second Hospital of Jilin University , 130041, Changchun, China, East Asia
| | - Yien Xiang
- Department of Hepatobiliary and Pancreatic Surgery, Second Hospital of Jilin University , 130041, Changchun, China, East Asia.,Jilin Engineering Laboratory for Translational Medicine of Hepatobiliary and Pancreatic Diseases , 130041, Changchun, China, East Asia
| | - Ruixin Lin
- Department of Hepatobiliary and Pancreatic Surgery, Second Hospital of Jilin University , 130041, Changchun, China, East Asia
| | - Yongsheng Yang
- Department of Hepatobiliary and Pancreatic Surgery, Second Hospital of Jilin University , 130041, Changchun, China, East Asia
| | - Xuewen Zhang
- Department of Hepatobiliary and Pancreatic Surgery, Second Hospital of Jilin University , 130041, Changchun, China, East Asia.,Jilin Engineering Laboratory for Translational Medicine of Hepatobiliary and Pancreatic Diseases , 130041, Changchun, China, East Asia
| |
Collapse
|
48
|
Flooring the Major Vessels with Falciform Ligament to Prevent Post-Pancreatectomy Hemorrhage. World J Surg 2020; 44:3478-3485. [PMID: 32533254 DOI: 10.1007/s00268-020-05637-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND One of the most severe pancreatic surgery complications is post-pancreatectomy hemorrhage (PPH). This study's aim was to evaluate the efficacy of flooring the major vessels with falciform ligament in preventing PPH after pancreatoduodenectomy (PD). METHODS This study was a retrospective review of 500 consecutive patients who underwent PD between Jan 2010 and Dec 2019 at Hiroshima University. Morbidities, including postoperative pancreatic fistula (POPF) or PPH and 90-day mortality, were analyzed. The study cohort was divided into two groups based on the time of surgery (2010-2016 and 2017-2019), i.e., before and after implementation of falciform ligament flooring method. The patient characteristics, operative parameters, clinicopathological factors, morbidity, and mortality were compared between the two periods. RESULTS Morbidity and mortality rates in the entire cohort were 21% and 1.4%, respectively. The incidence of Grade B/C POPF and PPH was 9.0% and 3.8%, respectively. There was no significant difference between the two periods with respect to Grade B/C POPF, morbidity rate, and mortality rate; however, the rate of Grade B/C PPH significantly decreased from 5.2 to 1.6% p = .027. On multivariate analysis, the absence of the falciform ligament flooring method was an independent PPH risk factor p = .003. CONCLUSIONS Falciform ligament flooring method may help decrease the incidence of PPH after PD.
Collapse
|
49
|
Wolk S, Radosa CG, Distler M, Held HC, Kühn JP, Weitz J, Welsch T, Hoffmann RT. Risk Factors for In-hospital Mortality After Transarterial Intervention After Postpancreatectomy Hemorrhage. Cardiovasc Intervent Radiol 2020; 43:1342-1352. [PMID: 32435837 PMCID: PMC7441056 DOI: 10.1007/s00270-020-02509-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 04/28/2020] [Indexed: 12/19/2022]
Abstract
Purpose Postpancreatectomy hemorrhage (PPH) is one of the leading causes of mortality after pancreatic resection. Late onset PPH is most often treated using a transarterial approach. The aim of this study was to analyze risk factors for in-hospital mortality after endovascular treatment. Methods Between 2012 and 2017, patients who were treated endovascular due to PPH were identified from a retrospective analysis of a database. Risk factors for mortality were identified by univariate analysis. Results In total, 52 of the 622 patients (8.4%) underwent endovascular treatment due to PPH. The primary technical success achieved was 90.4%. In 59.6% of patients, bleeding control was achieved by placing a stent graft and in 40.4% by coil embolization. The primary 30-day and 1-year patency of the placed covered stents was 89.3% and 71.4%, respectively. The 60-day mortality was 34.6%. The reintervention rate was higher after stent graft placement compared to coiling (39.3% vs. 21.1%, P = 0.012). In the univariate analysis the need for reintervention was associated with a higher in-hospital mortality (21.2% vs. 7.7%, P = 0.049). The use of an antiplatelet agent was associated with a decreased in-hospital mortality in the univariate (11.5% vs. 25%, P = 0.024) and multivariate analysis (HR 3.1, 95% CI 1.1-9, P = 0.034), but did not increase the risk of rebleeding. Conclusion Endovascular management of delayed PPH has a high technical success rate. Stent graft placement showed a higher reintervention rate. The need for reintervention was associated with a higher in-hospital mortality but did not differ between coiling and stent graft placement.
Collapse
Affiliation(s)
- Steffen Wolk
- Department of Visceral, Thoracic and Vascular Surgery, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Christoph Georg Radosa
- Institute for Diagnostic and Interventional Radiology, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Fetscherstr. 74, 01307, Dresden, Germany
| | - Marius Distler
- Department of Visceral, Thoracic and Vascular Surgery, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Hanns-Christoph Held
- Department of Visceral, Thoracic and Vascular Surgery, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Jens-Peter Kühn
- Institute for Diagnostic and Interventional Radiology, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Fetscherstr. 74, 01307, Dresden, Germany
| | - Jürgen Weitz
- Department of Visceral, Thoracic and Vascular Surgery, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Thilo Welsch
- Department of Visceral, Thoracic and Vascular Surgery, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Ralf-Thorsten Hoffmann
- Institute for Diagnostic and Interventional Radiology, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Fetscherstr. 74, 01307, Dresden, Germany.
| |
Collapse
|
50
|
Zhang L, Wang J, Jiang J, Shen J. The Role of Interventional Radiology in the Management of Late Postpancreaticoduodenectomy Hemorrhage. BIOMED RESEARCH INTERNATIONAL 2020; 2020:8851950. [PMID: 33415166 PMCID: PMC7752287 DOI: 10.1155/2020/8851950] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 11/15/2020] [Accepted: 11/30/2020] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To explore the role of interventional radiology (IR) in the management of late postpancreaticoduodenectomy hemorrhage (PPH). MATERIALS AND METHODS Patients who had late PPH (occurring >24 h after index operation) managed by the IR procedure in our institution between 2013 and 2018 were retrospectively analyzed. RESULT Hired patients who were diagnosed with grade B (n = 10) and C (n = 22) late PPH underwent 40 transcatheter arterial angiographies (TAA). The overall positive rate of angiography was 45.0% (18/40). Eighteen transcatheter arterial embolizations (TAEs) were performed, and the technical success rate was 88.89% (16/18). The rebleeding rate after embolization was 18.8% (3/16), and no severe procedure-related complications were recorded. The overall mortality of late PPH was 25.0% (8/32). CONCLUSION Nearly half of hemorrhagic sites in late PPH could be identified by TAA. TAE is an effective and safe method for the hemostasia of late PPH in patients with positive angiography results.
Collapse
Affiliation(s)
- Liang Zhang
- Department of Interventional Oncology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, No. 160 Pujian Road, Pudong, Shanghai 200127, China
| | - Jun Wang
- Department of Interventional Oncology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, No. 160 Pujian Road, Pudong, Shanghai 200127, China
| | - Jinhua Jiang
- Department of Interventional Oncology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, No. 160 Pujian Road, Pudong, Shanghai 200127, China
| | - Jialin Shen
- Department of Interventional Oncology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, No. 160 Pujian Road, Pudong, Shanghai 200127, China
| |
Collapse
|