The Role of Interventional Radiology in the Management of Late Postpancreaticoduodenectomy Hemorrhage

ENDOVASCULAR DIAGNOSTICS AND TREATMENT OF HEMORRHAGES IN MILITARY AND CIVILIAN PATIENTS FOLLOWING ABDOMINAL SURGERY

OBJECTIVE

The aim: The retrospective analysis of the angiographic picture and clinical results of endovascular treatment of patients with postoperative abdominal and gastrointestinal bleeding was carried out.

PATIENTS AND METHODS

Materials and methods: The results of 447 endovascular diagnostic and therapeutic interventions in 391 patients (46 military and 345 civilians) with postoperative bleeding performed from 2012 to 2022 were studied. According to computer tomography with contrast enhancement, the source of bleeding was identified in 216 (67.7%) cases.

RESULTS

Results: In 345 (88.2%) patients, it was possible to reliably identify the source of bleeding on angiography. In 46 (11.8%) patients with an unexplained source of bleeding, the target arterial pool was determined on the basis of localization, volume, and features of surgical intervention and considered as preventive interventions. A total of 447 endovascular hemostatic interventions were performed on 391 patients. A stent graft was installed in 27 patients, 420 embolization were performed in 364 patients. Thus, in 43 (11.0%) patients, embolization was performed repeatedly, in 12 cases - three times, in 1 case - four times. In 16 cases (15 cases of prophylactic embolization), endovascular hemostasis was ineffective and required subsequent surgical intervention.

CONCLUSION

Conclusions: Endovascular interventions are an effective method of diagnosis and treatment of postoperative abdominal bleeding. Prophylactic embolization allows you to prevent the recurrence of postoperative bleeding with an instrumentally undiagnosed source, however, you need to be prepared for the multi-stage treatment aimed at sequentially shutting down the collateral blood supply to the damaged area.

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

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

Impact of Vascular Anomalies on Pancreatoduodenectomy Procedure

Background

One of the critical steps during pancreatoduodenectomy (PD) procedure lies in identifying the complicated vascular anatomy of the resected area. The blood supply usually stems from branches of the celiac and the superior mesenteric arteries. However, only in 55-79% of surgeries, the anatomy of the blood vessels encountered by the surgeon is considered normal, while in the remaining cases, there are vascular variations that make these surgeries even more challenging. Any change or deviation from the known surgical course of PD makes surgery difficult and can result in an increase in intra/postoperative complications. In order to reduce difficulties encountered during PD, as well as reducing complication rates and improving surgical outcomes, a preliminary design, which includes preoperative identification of anatomical variations, is needed. The most accurate and accessible tool for identifying such variations is computed tomographic angiography (CTA). The aim of this retrospective study is to assess the prevalence of vascular anomalies encountered during PD, and examine whether there is an association between these anomalies and intra/postoperative morbidity and mortality.

Methods

A retrospective study over 5 years was performed at the HPB and Surgical Oncology Unit, Rambam Health Care Campus, Haifa, Israel. The charts of all patients submitted to PD were reviewed, and all patients with vascular anomalies were included. The types of anatomical variant as well as other information were collected. For statistical purposes, the group of patients with vascular anomalies was compared to a control group with identical demographic characteristics. A statistical analysis on possible association between vascular anomalies and intra/postoperative complications (mainly bleeding) was performed.

Results

During the aforementioned period, 202 patients underwent PD, and in 41 (20.3%) vascular anomalies were identified. The majority of these patients (32/41) had single anatomical variant, where two and three anatomical variants were identified in seven and two patients, respectively. The most common vascular anomaly was replaced right hepatic artery, noticed in 34 patients (83%). The most common indication for PD for both groups (anatomical variant and control group) was pancreas adenocarcinoma (56%). Intraoperative complication, in the form of bleeding, developed in 6/41 patients (14.6%) of the anatomical variant group and none in the control group. Postoperative complication rates, including post- pancreatoduodenectomy hemorrhage (PPH), postoperative pancreatic fistula (POPF), intra-abdominal abscess and wound infection were almost identical for both groups. One case of death within 30 days occurred, and it was in the anatomical variant group.

Conclusions

Anatomical vascular anomalies are a common variant encountered during PD, with RRHA being the most common. Although postoperative morbidity and mortality are not affected by the presence of these anomalies, intraoperative bleeding rate is higher in this specific group, thus; a preoperative diagnosis by means of CTA is mandatory.