Management of vascular complications after pancreaticoduodenectomy (PD): reducing the numbers of failure to rescue.

Abstract

Background: No consensus on the treatment of PPH exists and failure to rescue rates still remain high, ranging from 14-47% after grade B or C PPH according to ISGPS classification. The aim of this study is to analyze mortality and morbidity in surgical, endoscopic and endovascular treated patients for PPH. Methods: A database of 974 PD patients from four medical centers in the Netherlands (January 2006- December 2015) was analyzed retrospectively. Results: PPH occurred in 9,0% (88/974), of which 15.9% developed early PPH (14/88) and 84.1% delayed PPH (74/88). 16 patients died in the delayed PPH group (mortality rate of 21,6%). Hemodynamic stability and presence of risk factors as abdominal abscess, sepsis or pancreatic leak, significantly increased the failure to rescue rate of delayed PPH (resp. p=0.011, p=0.014). A failure to rescue rate of 22,5% for angiography (9/40), 42.9% for relaparotomy (3/7) and 33.3% for endoscopy (2/6) in the intention-to-treat analysis with delayed PPH was obtained. Primary endovascular treatment was successful in 57.9% (22/38), endoscopic treatment in 83.3% (5/6) and surgical treatment in 57.1% (4/7), no significant difference in success rates between the primary treatment modalities for delayed PPH was obtained (p= 0.568). Conclusion: No significant difference in success rates and morbidity between the three treatment modalities was observed in this large cohort. In order to develop an evidence based treatment protocol for PPH this cohort will be enlarged nationwide.