Post-pancreaticoduodenectomy Hemorrhage Research Articles

Optimizing the Management Strategies of Delayed Post-Pancreaticoduodenectomy Hemorrhage

Objective: To optimize the management strategies of delayed post-pancreaticoduodenectomy hemorrhage (PPH) by evaluating data from a high-volume pancreatic center. Summary Background Data: Delayed PPH is a potentially lethal complication. The management of delayed PPH remains controversial. Methods: Patients who underwent pancreaticoduodenectomy between July 2018 and June 2023 were identified from an institutional database. The clinical scenarios, management, and outcomes of patients with delayed PPH (>5 d postoperatively) were analyzed. Results: Out of the 2013 patients who underwent elective pancreaticoduodenectomy, 130 (6.5%) with delayed PPH were identified. The overall mortality was 15.4%. The success rates of endoscopy, angiographic intervention, and relaparotomy in treating delayed PPH were 54.5%, 56.5%, and 68.8%, respectively. For PPH from the hepatic arteries or their branches, complete blockade of the common or proper hepatic artery (C/PHA) was performed in 17 patients, either by coil embolization (n=7) or surgical ligation (n=10). Coil embolization of the C/PHA resulted in significant infarction of the left liver in 2 patients. No postoperative liver infarction occurred in patients who underwent ligation of the C/PHA during relaparotomy. Ten patients underwent suture repair of the C/PHA 13 times during relaparotomy. Arterial ligation achieved a significantly higher success rate of hemostasis than suture repair of the C/PHA during relaparotomy (100% vs. 30.8%, P<0.001). Conclusions: Angiography should be attempted first in managing hemodynamically stable delayed PPH. Arterial ligation was preferred for bleeding from the hepatic arteries during relaparotomy with minor consequences for the liver.

Endovascular Management of Postoperative Hemorrhage after Pancreaticoduodenectomy

Abstract Objective The aim of the study was to assess the safety and efficacy of endovascular management for postpancreaticoduodenectomy hemorrhage. Materials and Methods A retrospective analysis of patients who underwent endovascular management for hemorrhage after pancreatic surgery between January 2015 to December 2020 was performed. Patient demographics, clinical presentation, angiography findings, endovascular procedure, technical success, clinical success, and complications were assessed. Results Seventeen patients, comprising 14 (82.4%) males and 3 (17.6%) females, aged 37 to 68 years underwent endovascular management for postpancreatectomy hemorrhage. Patients presented with hemorrhage on their postoperative days 4 to 22 (mean: 9.8th day; median: 8th day); the presentation was with extraluminal hemorrhage in 11 patients (64.7%) and intraluminal hemorrhage in 6 patients (35.2%). The gastroduodenal artery (GDA) stump (10 patients, 58.8%) was the most commonly involved artery. The majority of cases were treated using coils as embolizing agents (13/17 patients, 76.5%). The technical and clinical success rates were 100%. The complication rate was 5.9% (1/17) and the mortality rate was 11.8% (2/17). The relaparotomy rate was 23.5% (4/17); however, none of the relaparotomy was for hemorrhage. Conclusion Endovascular treatment provides a minimally invasive, safe, and effective method for the management of pancreaticoduodenectomy hemorrhage.

Comparing the Clinical Efficacy of Coil Embolization in GDA Stump versus Common Hepatic Artery in Postoperative Hemorrhage after Pancreatoduodenectomy

Hemorrhage after pancreaticoduodenectomy is an uncommon but fatal complication. In this retrospective study, the different treatment modalities and outcomes for treating post-pancreaticoduodenectomy hemorrhage are analyzed. Our hospital imaging database was queried to identify patients who had undergone pancreaticoduodenectomy during the period of 2004-2019. The patients were retrospectively split into three groups, according to their treatment: conservative treatment without embolization (group A: A1, negative angiography; A2, positive angiography), hepatic artery sacrifice/embolization (group B: B1, complete; B2, incomplete), and gastroduodenal artery (GDA) stump embolization (group C). There were 24 patients who received angiography or transarterial embolization (TAE) treatment 37 times (cases). In group A, high re-bleeding rates (60%, 6/10 cases) were observed, with 50% (4/8 cases) for subgroup A1 and 100% (2/2 cases) for subgroup A2. In group B, the re-bleeding rates were lowest (21.1%, 4/19 cases) with 0% (0/16 cases) for subgroup B1 and 100% (4/4 cases) for subgroup B2. The rate of post-TAE complications (such as hepatic failure, infarct, and/or abscess) in group B was not low (35.3%, 6/16 patients), especially in patients with underlying liver disease, such as liver cirrhosis and post-hepatectomy (100% (3/3 patients), vs. 23.1% (3/13 patients); p = 0.036, p < 0.05). The highest rate of re-bleeding (62.5%, 5/8 cases) was observed for group C. There was a significant difference in the re-bleeding rates of subgroup B1 and group C (p = 0.00017). The more iterations of angiography, the higher the mortality rate (18.2% (2/11 patients), <3 times vs. 60% (3/5 patients), ≥3 times; p = 0.245). The complete sacrifice of the hepatic artery is an effective first-line treatment for pseudoaneurysm or for the rupture of the GDA stump after pancreaticoduodenectomy. Hepatic complications are not uncommon and are highly associated with underlying liver disease. Conservative treatment, the selective embolization of the GDA stump, and incomplete hepatic artery embolization do not provide enduring treatment effects.

Endovascular treatment for delayed post-pancreaticoduodenectomy hemorrhage of unusual origin (splenic artery branch).

The objective of this study was to investigate the method, efficacy, and safety of endovascular treatment (EVT) of delayed splenic artery branch (SAB) hemorrhage after pancreaticoduodenectomy. From March 2019 to January 2022, all patients underwent EVT of SAB for delayed post-pancreaticoduodenectomy hemorrhage were included. Demographic, laboratory, angiographic, and clinical follow-up data were collected and analyzed. A total of eight patients were enrolled. In two patients, celiac axis angiography alone failed, but selective splenic artery (SA) angiography demonstrated the SAB bleeding; SAB erosions in four patients with recurrent bleeding were successfully detected by a second angiography; four patients underwent balloon catheter placement at the SA for temporary hemostasis and to further confirm the SAB bleeding before the subsequent EVT. Superselective embolization was performed in only one patient (12.5%; 1/8); covered stent implantation at the SA was performed in two patients (25%; 2/8); Embolization of the SA was performed in the remaining five patients (62.5%; 5/8). The technical success rate, clinical success rate, and in-hospital mortality were 100.0%, 87.5%, and 25%, respectively. No severe complications related to EVT occurred. EVT of SAB for delayed post-pancreaticoduodenectomy hemorrhage is effective and safe. An awareness of the SAB as a potential bleeding source, together with appropriate endovascular procedures including selective SA angiography, repeat angiography, balloon catheter placement at the SA, and applicable hemostasis protocol, could achieve a high success rate of managing SAB hemorrhage.

Arterial Divestment and Resection in Post-neoadjuvant Pancreatic Adenocarcinoma.

IntroductionThe advent of neoadjuvant therapy in the management of pancreatic adenocarcinoma has significantly improved the prognosis of the disease. Nevertheless, the only chance of long-term disease-free survival in pancreatic cancer is achieved with complete tumor resection, and artery involvement by the tumor is one of the major determinants in its resectability. We aim to evaluate the feasibility of a novel technique, namely, the periarterial divestment, which has allowed surgeons to clear the tumor tissues off the visceral arteries without the need for arterial reconstruction.Materials and methodsIn this single-center, retrospective, descriptive, cross-sectional study done between August 2019 and July 2021, seven consecutive patients with histologically confirmed pancreatic ductal adenocarcinoma (PDAC) who underwent neoadjuvant therapy were included. Arterial divestment was performed in six of seven patients and arterial reconstruction was performed in one of the patients. The data on perioperative and the early oncological outcome were recorded.ResultsFive patients underwent periarterial divestment, one underwent sub-adventitial divestment, and one underwent superior mesenteric artery reconstruction due to deeper tumor infiltration into the arterial wall. The intraoperative frozen section of periarterial tissue was positive in three cases and the final histopathological specimen after the divestment showed a positive margin in two of the cases. The clinically significant postoperative pancreatic fistula was noted in two patients, and one patient experienced grade C post-pancreaticoduodenectomy hemorrhage due to a hepatic artery pseudoaneurysm. Four patients, all of whom underwent periarterial divestment, experienced postoperative diarrhea. There were no mortality and the median postoperative hospital stay was seven days.ConclusionThe need for arterial reconstruction in borderline and locally advanced pancreatic cancer can be avoided by using the periarterial divestment technique. Divestment of arteries is technically feasible and can be carried out safely without compromising the patient's oncological outcome. However, further validation of this technique must be done by well-designed studies with a greater sample size.

Risk Score for Prediction of Severe Postoperative Complications After Pancreaticoduodenectomy

Introduction Morbidity after pancreaticoduodenectomy (PD) still remains high. Postoperative pancreatic fistula (POPF) is the most common cause of increased morbidity after PD. Assessment of predictability of risk score for severe postoperative complications was the objective of this study.&#x0D; MethodsThis was a retrospective observational study. Patients undergoing pancreaticoduodenectomy at Tribhuvan University Teaching Hospital (TUTH) between January 2017 to December 2017 were included in the study. Variables were recorded from case sheets of the patients. The “Risk Score” was calculated using the pancreatic duct diameter and body mass index (BMI). Association of risk score and severe postoperative complications were analyzed.&#x0D; ResultsA total number of patients were 43, including 23 (53.5%) males and 20 (46.5%) females. The mean age was 57.09 ± 11.85 years ranges from 29 years to 76 years. The POPF and delayed gastric emptying (DGE) was 23.3% (10/43); and post-pancreaticoduodenectomy hemorrhage (PPH) was 11.6% (5/43). Severe postoperative complications were present in 13.9% (6/43) patients. In univariate analysis, pancreatic duct diameter (p=0.045) and Risk Score (p=0.02) were significantly associated with severe postoperative complications after PD. However none of them were significant in multivariate analysis.&#x0D; ConclusionRisk score failed to predict severe postoperative complication after pancreaticoduodenectomy.

Hemostatic Spray; A Rescue to Severe Post-pancreaticoduodenectomy Hemorrhage - A Novel Technique to use

Pancreaticoduodenectomy (Whipple’s Procedure) being an immensely intricate procedure, is accompanied by morbidities out of which some can pose a considerable threat to human life. A morbidity worth discussing is post-pancreaticoduodenectomy hemorrhage. Being classified as early or late and mild, moderate or severe, PPH can be life threatening leading to hypovolemic shock and death if untreated. We describe a case of a 52 year old South-Asian female, who underwent pancreaticoduodenectomy with pancreatico-gastrostomy for a non metastatic periampullary tumor, experienced an intraluminal post pancreaticoduodenectomy hemorrhage on fourth postoperative day leading to hypovolemic shock, with no evidence of extraluminal bleed. Urgent upper gastrointestinal endoscopy showed ulcerated pancreaticogastric anastomosis and marginal ulcer at the site of anastomosis of small intestine and stomach. Hemostatic spray was applied and hemostasis was secured. After meticulous literature review, it became evident that hemostatic spray has been used for a variety of cases of upper gastrointestinal bleeding but has never been utilized for the post-pancreaticoduodenectomy hemorrhage as delineated in the concise discussion of the article.

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

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.

Post pancreaticoduodenectomy hemorrhage: A retrospective analysis of incidence, risk factors and outcome.

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.

Embedment of the gastroduodenal artery stump into the jejunal serosa: A new technique aiming to prevent post-pancreatectomy hemorrhage

Post-pancreaticoduodenectomy hemorrhage has an estimated incidence of 5% and a mortality rate of 11-38%. Vascular erosion resulting from pancreatic leak and skeletonization of the arterial wall during pancreatic mobilization may be the two possible mechanisms responsible for this complication, which most commonly affects the gastroduodenal artery stump. A novel technique of wrapping up the gastroduodenal artery stump into the jejunal serosa to decrease postoperative hemorrhage is presented.

Risk factors for 30-day unplanned reoperation after pancreatoduodenectomy: A single-center experience

The purpose of this study was to investigate the rate and reasons and also the risk factors for unplanned reoperation after pancreatoduodenectomy (PD) in a single center. This retrospective analysis included patients who underwent PD in the First Affiliated Hospital of Nanchang University between January 2010 and January 2018. The patients were divided into nonreoperation and reoperation groups according to whether they underwent unplanned reoperation following the primary PD. The incidence and reasons were examined. In addition, multivariate logistic regression analysis was performed to identify the risk factors for unplanned reoperation. Of the 330 patients who underwent PD operations, 22 (6.67%) underwent unplanned reoperation. The main reasons for reoperation were postpancreaticoduodenectomy hemorrhage (PPH) (12/22 [54.5%]) and pancreaticoenteric anastomotic (PEA) leak (5/22 [22.7%]). Multivariate logistic regression analyses identified that diabetes (odds ratio [OR], 3.70; 95% confidence interval [CI], 1.06-12.90; P = 0.04), intraoperative blood loss ≥400 mL (OR, 4.06; 95% CI, 1.29-12.84; P = 0.02), occurrence of postoperative complications in the form of PPH (OR, 30.67; 95% CI, 8.85-106.31; P < 0.001), and PEA leak (OR, 11.53; 95% CI, 3.03-43.98, P < 0.001) were independent risk factors for unplanned reoperation. Our results suggest that diabetes, intraoperative blood loss ≥400 mL, PPH, and PEA leak were independent risk factors for unplanned reoperation after primary PD.

Intra-abdominal hemorrhage following 739 consecutive pancreaticoduodenectomy: Risk factors and treatments.

Post-pancreaticoduodenectomy hemorrhage (PPH) is a potentially lethal complication. The objective of this study was to explore the risk factors of PPH and to evaluate the treatment options. Clinical data of 739 consecutive patients undergoing pancreaticoduodenectomy between 2009 and 2017 were collected from a prospectively maintained database. Univariate and multivariate analysis was performed by logistic regression model to evaluate potential risk factors associated with early and late PPH. The morbidity of PPH was 8.7% (64/739), while the mortality was 12.5% (8/64). Twenty-two (34.4%) patients developed PPH within postoperative day 1 (early PPH) whereas 42 (65.6%) patients after postoperative day 1 (late PPH). No significant risk factor was identified associated with early PPH, whereas pancreatic duct diameter <0.4cm, and intra-abdominal complications, such as pancreatic fistula, intra-abdominal abscess, and delayed gastric emptying, were independently correlated with late PPH. There were 10 (15.6%) grade A, 28 (43.8%) grade B, and 26 (40.6%) grade C bleedings. The bleeding sites were verified by endoscopy, angiography, and/or exploratory laparotomy in 23 of 54 (42.6%) patients with grade B or C hemorrhage. Seven out of nine (78%) patients with arterial bleeding were cured by angiography and embolization, while 10 of 11 (90.9%) patients with anastomotic, venous, or retroperitoneum bleeding were rescued by laparotomy. Ten patients with grade A and 22 patients with grade B or C hemorrhage were treated successfully by blood transfusion and hemostatic medications. Hemorrhage following pancreaticoduodenectomy is a common and lethal complication. Treatment strategies should be tailored according to different etiologies.

Pancreaticoduodenal resection for carcinoma head of pancreas – the influence of margin status on survival

Aim: To evaluate the influence of margin status on survival following resection for carcinoma head of pancreas (CaHOP). Methods: A retrospective analysis of prospectively maintained database of patients undergoing a Pancreaticoduodenal resection (PDR) for CaHOP. 547 patients underwent a PDR at a tertiary care center from Jan 2001 till Dec 2013. Of these, 24 patients (4.4%) operated for CaHOP form the study material. Margins were defined as macroscopically positive (R2), microscopically positive (R1), negative margins (R0) and close margins which were less than 1mm (Rc). Results: 13/24 (54.2%) patients were R0, 6/24 (25%) were R1, 3/24 (12.5%) were Rc. 2 (8.3%) patients had positive margins on intra-operative frozen section and underwent a total pancreaticoduodenectomy (TPD). 1 (4.2%) patient expired postoperatively following a classical PD . The postoperative morbidity included post pancreaticoduodenectomy hemorrhage (PPH)(n=3, 12.5%), pancreaticojejunostomy (PJ) leak (n=5, 22.7%), bile leak (n=2,8.3%) and DGE (n=4,16.7%) The overall survival of these patients was 15.3 months. The survival following R0 resection was 15.5 months, 13.9 months for R1 and Rc resection and 20 months for TPD. Patients undergoing TPD for positive intraoperative margin on frozen section had better survival than those with R1 or close surgical (Rc) margins (20 months vs 13.9 months) though there was no statistically significant difference based on margin status of the patients because of small group size. Conclusion: R1 and Rc resections fare similarly. TPD for positive resection margins provides better overall survival with acceptable morbidity. Larger prospective trials are required to validate these results.

Post-pancreaticoduodenectomy hemorrhage: DSA diagnosis and endovascular treatment.

ObjectiveTo explore the diagnostic value of digital subtraction angiography (DSA) and the effectiveness of endovascular treatment for a post-pancreaticoduodenectomy hemorrhage (PPH).ResultsDuring the DSA examination, positive results were found in 29 patients, yielding a positive rate of 69.0%. The manifestations of the DSA examination included contrast medium extravasation, pseudoaneurysm, and artery walls coarse. All 29 patients with positive results underwent endovascular treatment, including transartery embolization (TAE) in 28 patients and covered stents placement in one patient. The technical success and clinical success rates were 100% and 72.4%, respectively. Re-bleeding occurred in 8 of the 29 patients after the first treatment (27.6%). The mortality of PPH was 17.2% (5 of 29). Two of the five PPH patients died following severe infections, and three died from multiple organ failure.Materials and MethodsA DSA examination was conducted using clinical and imaging data of 42 patients, and endovascular treatment for delayed PPH was retrospectively analyzed.ConclusionsDSA examination is a minimally invasive and rapid method for the diagnosis of delayed PPH. For patients with positive DSA results, endovascular treatment can be performed rapidly, safely, and effectively. Therefore, the DSA examination and endovascular treatment could be considered a preferred treatment approach for delayed PPH.

Clinical impact of diagnostic imaging prior to definitive angiography for post-pancreaticoduodenectomy hemorrhage

Clinical impact of diagnostic imaging prior to definitive angiography for post-pancreaticoduodenectomy hemorrhage

Initial results after implementation of a post pancreaticoduodenectomy hemorrhage protocol

Initial results after implementation of a post pancreaticoduodenectomy hemorrhage protocol

Post-pancreaticoduodenectomy hemorrhage risk factors, managements and outcomes

Post-pancreaticoduodenectomy (PD) hemorrhage (PPH) is an uncommon but serious complication. This retrospective study analyzed the risk factors, managements and outcomes of the patients with PPH. A total of 840 patients with PD between 2000 and 2010 were retrospectively analyzed. Among them, 73 patients had PPH: 19 patients had early PPH and 54 had late PPH. The assessment included the preoperative history of disease, pancreatic status and surgical techniques. Other postoperative complications were also evaluated. The incidence of PPH was 8.7% (73/840). There were no independent risk factors for early PPH. Male gender (OR=4.40, P=0.02), diameter of pancreatic duct (OR=0.64, P=0.01), end-to-side invagination pancreaticojejunostomy (OR=5.65, P=0.01), pancreatic fistula (OR=2.33, P=0.04) and intra-abdominal abscess (OR=12.19, P<0.01) were the independent risk factors for late PPH. Four patients with early PPH received conservative treatment and 12 were treated surgically. As for patients with late PPH, the success rate of medical therapy was 27.8% (15/54). Initial endoscopy was operated in 12 patients (22.2%), initial angiography in 19 (35.2%), and relaparotomy in 15 (27.8%). Eventually, PPH resulted in 19 deaths. The main causes of death were multiple organ failure, hemorrhagic shock, sepsis and uncontrolled rebleeding. Careful and ongoing observation of hemorrhagic signs, especially within the first 24 hours after PD or within the course of pancreatic fistula or intra-abdominal abscess, is recommended for patients with PD and a prompt management is necessary. Although endoscopy and angiography are the standard procedures for the management of PPH, surgical approach is still irreplaceable. Aggressive prevention of hemorrhagic shock and re-hemorrhage is the key to treat PPH.

Post-Pancreaticoduodenectomy Hemorrhage of Unusual Origin: Treatment with Endovascular Embolization and the value of preoperative CT Angiography

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