Sentinel Bleeding Research Articles

A Systematic Review of Mortality Associations in Patients who Develop Tracheoinnominate Artery Fistula Following Tracheostomy.

Tracheoinnominate artery fistulas (TIFs) are a rare but deadly complication of tracheostomy. Tracheoinnominate artery fistula cases in the literature were summarized in order to understand mortality associations. MEDLINE was searched for studies reporting individual characteristics of patients with TIFs after tracheostomy, excluding cases without tracheostomy or with additional procedures at the tracheostomy site. This study followed PRISMA guidelines. 121 TIF patients from 18 case series and 46 case reports were included. The median age was 40years, and 52.9% were male. The overall mortality rate was 64.5%. There were differences in mortality between cases that presented initially with vs without sentinel bleeding (odds ratio [OR] .34; CI [confidence interval] .16-.73; P = .006). The mortality rate also differed in whether or not the tracheostomy cuff was over-inflated for temporary hemostasis during resuscitation (OR 3.57 (CI 1.57-8.09); P = .002). Treatment compared to no treatment had lower mortality rates (OR .11 (CI 0.04-.32); P < .001); no differences were found if treatment was endovascular vs open surgical. Mortality is a major concern after detection of a TIF and resuscitation paired with endovascular or open surgical intervention is imperative. Rapidly investigating sentinel bleeds and intervening upon hemorrhage with temporary cuff over inflation may lead to improved outcomes.

Development and Validation of a Model for Postpancreatectomy Hemorrhage Risk

Postpancreatectomy hemorrhage (PPH) due to postoperative pancreatic fistula (POPF) is a life-threatening complication after pancreatoduodenectomy. However, there is no prediction tool for early identification of patients at high risk of late PPH. To develop and validate a prediction model for PPH. This retrospective prognostic study included consecutive patients with clinically relevant POPF who underwent pancreatoduodenectomy from January 1, 2009, to May 20, 2023, at the University Hospital Mannheim (derivation cohort), and from January 1, 2012, to May 31, 2022, at the University Hospital Dresden (validation cohort). Data analysis was performed from May 30 to July 29, 2023. Clinical and radiologic features of PPH. Accuracy of a predictive risk score of PPH. A multivariate prediction model-the hemorrhage risk score (HRS)-was established in the derivation cohort (n = 139) and validated in the validation cohort (n = 154). A total of 293 patients (187 [64%] men; median age, 69 [IQR, 60-76] years) were included. The HRS comprised 4 variables with associations: sentinel bleeding (odds ratio [OR], 35.10; 95% CI, 5.58-221.00; P < .001), drain fluid culture positive for Candida species (OR, 14.40; 95% CI, 2.24-92.20; P < .001), and radiologic proof of rim enhancement of (OR, 12.00; 95% CI, 2.08-69.50; P = .006) or gas within (OR, 12.10; 95% CI, 2.22-65.50; P = .004) a peripancreatic fluid collection. Two risk categories were identified with patients at low risk (0-1 points) and high risk (≥2 points) to develop PPH. Patients with PPH were predicted accurately in the derivation cohort (C index, 0.97) and validation cohort (C index 0.83). The need for more invasive PPH management (74% vs 34%; P < .001) and severe complications (49% vs 23%; P < .001) were more frequent in high-risk patients compared with low-risk patients. In this retrospective prognostic study, a robust prediction model for PPH was developed and validated. This tool may facilitate early identification of patients at high risk for PPH.

Tracheoinnominate Artery Fistula After Tracheostomy: A Systematic Literature Review of Associations With Mortality

Tracheoinnomate artery fistulas (TIF) are a rare but deadly complication of tracheostomy. This study summarizes TIF cases in the literature and seeks to understand associations with mortality. MEDLINE was searched (up to May 2021) for studies reporting individual clinical and demographic characteristics of patients with TIFs after tracheostomy. Exclusion criteria were: no tracheostomy tube in place at the time of fistula or additional procedures performed at the tracheostomy site. This study was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A total of 122 TIF patients from 18 case series and 46 case reports were included. The median age was 40.9 years (range: 4-85, interquartile range: 20.9-60.9 years) and 53.3% (64 of 120) were male. Trauma was the leading indication for tracheostomy (26.2%, 32 of 122), followed by head/neck cancer (20.5%, 25 of 122) and structural malformation (19.7%, 24 of 122). Mortality characteristics are summarized in the Table. Overall mortality rate was 64.8% (79 of 122), with a 15.4% higher rate in females than males (P = .077). There was no significant difference in the median number of days between tracheostomy and TIF detection between those who survived their TIF vs those who died (46 days vs 23 days, P = .077). There was a significant difference in mortality between cases that initially presented with vs without sentinel bleeding (50% [25 of 50] vs 75% [54 of 72], P = .005). The presence or absence of frank hemorrhage also showed a significant difference in mortality (59.6% [53 of 89] vs 78.8% [26 of 33], P = .035). Mortality differed in whether or not the tracheostomy cuff was overinflated for temporary hemostasis during resuscitation (52.2% [35 of 67] vs 80% [44 of 55], P < .001). A total of 27 cases received endovascular management, 2 of which ultimately needed open surgery. No difference in mortality was found between endovascular and surgical management, yet both of these were superior to no treatment (48.6% [36 of 74] vs 89.6% [43 of 48], P < .001). Of the 49 cases definitively managed with open surgery, there were 36 innominate artery resections, 15 tracheal reconstructions, and 12 innominate artery reconstructions. Mortality is a major concern and resuscitation paired with endovascular or surgical intervention is imperative. Investigating sentinel bleeds in a timely fashion and intervening upon hemorrhage with temporary cuff overinflation may lead to improved outcomes.TableMortality characteristicsMortalityP valueDied64.7 (79/122)Sex Male57.8 (37/64).077 Female73.2 (41/56)Age, groups in years 4-2563.8 (23/36).756 26-5061.4 (27/44) >5069.0 (29/42)Sentinel bleed Present50 (25/50).005 Absent75 (54/72)Hemorrhage Present59.6 (53/89).035 Absent78.8 (26/33)Cuff over inflation Performed52.2 (35/67)<.001 Not performed80 (44/55)Endovascular vs surgical management Endovascular48.0 (12/25).938 Surgical49.0 (24/49)Definitive treatment vs no treatment Endovascular or Surgical48.6 (36/74)<.001 No treatment89.6 (43/48)Values represented as percentage and count (condition present/total). Open table in a new tab

Management and outcomes of pseudoaneurysms presenting with late hemorrhage following pancreatic surgery: A six-year experience from a tertiary care center.

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 ofsix-years at our tertiary care center. Between 2014 and 2020, 616 pancreatic surgeries were performed and 25 patients had late hemorrhage (occurring > 24hours post-operatively). The clinical parameters related to late hemorrhage, associated complications, embolization details, treatment success and their short-and long-term outcomes were analyzed. 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 (2.5g/dL vs. 1.5g/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. 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.

A Clinical Series in Patients with Naso-Pharyngeal Cancer and Their Outcomes with Stent Graft Treatment for Sentinel Bleeding to Prevent Frank Carotid Rupture

The purpose of this study was to evaluate the safety and effectiveness of heparin-bonded VIABAHN stent graft for carotid rupture in patients with nasopharyngeal carcinoma (NPC). A total of 1,596 patients with NPC were enrolled. Fifteen patients (8 male and 7 female), who developed carotid artery rupture (CAR) after radiotherapy between January 2016 and June 2019, were retrospectively analyzed. Complications and mortality were assessed at 12months postoperatively. The incidence of carotid burst syndrome in the NPC cohort was 0.94%. The distribution of site of arterial rupture was as follows: common carotid artery (4 cases), C1 segment of internal carotid artery (8 cases), and C2 segment of internal carotid artery (3 cases). All patients successfully underwent emergency deployment of the heparin-bonded VIABAHN to seal off the ruptured carotid artery. The survival rate as of 12-month follow-up was 80.0%. Three patients died of short-term rebleeding, lung infection, and tumor progression. No stent-related complications occurred in our cohort. Heparin-bonded VIABAHN-covered stents may be a safe and effective treatment option for carotid rupture in patients with NPC.

844: SUCCESSFUL TREATMENT OF TRACHEOINNOMINATE ARTERY FISTULA WITH INNOMINATE ARTERY ANGIOPLASTY/STENT

Introduction: Tracheo-innominate artery fistula(TIF) is an uncommon and life-threatening complication of tracheostomy with a reported incidence of 0.7%. However, the mortality rate is nearly 100% if it is not treated urgently with definitive management. The initial bleeding may be mild, but these sentinel bleeding events often precede a massive hemorrhage. Early diagnosis is the most important factor for successful management of a TIF. Here we describe a patient who presented with TIF after sentinel bleeding and whose condition was stabilized with an endovascular stent. Description: 77 year old female with history of severe mitral regurgitation underwent mitral valve repair with annuloplasty; 2 weeks later she developed shortness of breath secondary to ascending aorta pseudoaneurysm which was repaired. Her hospital course was complicated by chronic respiratory failure secondary to recurrent multifocal pneumonia and ARDS, necessitating the need of percutaneous bronchoscopy. Patient had episode of tracheal bleed 3 weeks after the percutaneous tracheostomy for which immediate CT angiography which showed tracheo-innominate artery fistula with sentinel bleed; for which patient underwent successful innominate artery angioplasty and stent with a Gore 8*39 VBX stent. Post angioplasty, fiberoptic bronchoscopy was performed with extensive blood in airways throughout, which was lavaged. The post operative course was uneventful and she was discharged 4 days later to long term acute care. Discussion: The main treatment of TIF is a surgical procedure with ligation of the innominate artery and bypass grafting of the distal innominate artery. Morbidity and mortality rates are high after surgical operations for TIF. Recently, endovascular procedures involving stent graft implantation have significantly improved, and can be safely performed as an alternative to the traditional open surgical method in selected circumstances. Although endovascular stenting does not guarantee the complete elimination of TIF and it has some complications of graft infection, occlusion, and rebleeding due to tracheal erosion. However, endovascular repair of TIF via stent is a safe, effective, and minimally invasive treatment for patients in poor clinical conditions and is an alternative to traditional open surgical treatment.

Cervical length and risk of unplanned cesarean hysterectomy in patients with placenta accreta-previa spectrum

Short cervix and sentinel bleeding have been associated with unscheduled delivery in patients with placenta previa. We sought to determine if these factors were associated with unplanned delivery in patients with placenta previa and placenta accreta spectrum (PAS).

S2117 The Hardest Working Clot: When a Sentinel Bleed Results in Early Detection of an Aorto-Esophageal Fistula Caused by a Transcatheter Aortic Valve Replacement

Introduction: A transcatheter aortic valve replacement (TAVR) carries a 2% risk of postoperative upper gastrointestinal bleeding. It presents as extensive bleeding resulting in hemorrhagic shock or respiratory failure. In this case, an early clot with sentinel bleeding prevented the widening of a full thickness aortoesophageal fistula formed from the TAVR placement, was symptomatic enough to prompt an earlier esophagogastroduodenoscopy (EGD) and prevented a probable fatality. Case Description/Methods: An 85-year-old male with a past medical history of AAA repair, GERD, HLD, TIA, aortic dissection s/p coronary bypass graft, AS with TAVR 5 months prior presented with hematemesis after initiating colonoscopy bowel prep. He also had unintentional 30-lb weight loss over 3 months, fecal incontinence, and melena. Medications include a daily aspirin. Abdominal CT demonstrated an 8cm aortic arch aneurysm, a 5cm descending thoracic aortic aneurysm, and a 5.8 x 4 cm collection posterolateral to the aorta with proximal dilation of the esophagus. EGD demonstrated a partially obstructing protruding mass in the esophagus 20 cm from the incisors with sentinel bleeding from an adherent clot. The mass was determined to be extrinsic compression from the aortic arch aneurysm with the TAVR seen through the aortoesophageal fistula (Image 1A-1B). The stomach and duodenum were unremarkable. Patient was transferred to vascular surgery where a 1cm compressed Amplatzer Vascular Plug II embolization and reinforcement of the endoleak was done. Patient remained hemodynamically stable and discharged home with a vascular follow up. Discussion: Aorto-esophageal fistula following TAVR is a rare complication with a wide etiology ranging from infections, antithrombotic use, pressure necrosis, angiodysplasia, underlying PUD, or uncontrolled comorbidities such as HTN. Our patient’s risk factors were his elderly age, comorbidities, use of daily aspirin, and contribution from the pressure or ischemic necrosis of the aortic aneurysm compressing on the esophagus. Presentation involves hemoptysis, chest pain, hemorrhagic shock, respiratory failure and frank bleeding. CTA is considered the initial test of diagnosis as endoscopy, though sensitive, could rupture the clot and unleash massive bleeding. In this case, sentinel bleeding and visualization of the TAVR through the fistula was enough to diagnose and retreat to be treated appropriately with embolization and reinforcement.Figure 1.: Esophageal mass with pathology.

Pseudoaneurysms after Le Fort I Osteotomy at a Single High-surgical-volume Institution

The Le Fort I maxillary osteotomy remains a workhorse surgical technique for addressing dentofacial deformities; however, significant complications can arise. One of the most serious complications is a pseudoaneurysm that results from injury to a terminal branch of the internal maxillary artery. The bleeding episodes normally develop 10 days to 4 weeks post-hospital discharge. Typically, these are minor sentinel bleeding preceding a hemorrhagic episode that results in an emergency room visit. While rare, significant morbidity has been reported, and bleeding can be rapid and in some instances mortal. While definitive treatment of pseudoaneurysms via embolization has proven successful, significant postoperative risks to patients exist due to the delay in symptom presentation and identification as well as embolism morbidities. The purpose of this investigation is to determine the incidence of pseudoaneurysms after Le Fort I osteotomy at a single high-surgical-volume institution and to report treatment options and outcomes of patients who experienced this problem.The billing directory for CPT codes corresponding to single, 2- and 3-piece Le Fort I osteotomies was searched from January 1998 to December 2020. All cases of pseudoaneurysm arising post-surgically performed over this 22-year period were identified. Out of 1,768 Le Fort I osteotomies performed, 4 cases of pseudoaneurysm were identified. The calculated incidence rate of this complication was 0.2%, all 4 elected embolization in which embolization was successful with no consequence to any. All 4 patients were male. In all cases, the major bleed was preceded by several smaller bleeds. Two of the 4 patients required blood transfusion; however, 1 of those patients declined administration of blood products for religious reasons. In this patient, pseudoaneurysms developed bilaterally.Although rare, vascular pseudoaneurysms can be life-threatening. Early detection of prodromal symptoms is vital to proper identification and definitive treatment. Patients must also be extensively counseled on the importance of eliminating exertional activity for 6 weeks postoperatively.

Tracheoinnominate Artery Fistula.

This simulation provides training for emergency medicine residents in the stepwise management of a patient who presents with bleeding from a tracheoinnominate artery fistula. Additional learners who might benefit from this simulation are otolaryngology and general surgery residents as well as critical care fellows. Hemorrhage from a tracheoinnominate artery fistula (TIAF) is a rare but life-threatening complication in a patient with a recent tracheostomy. This complication occurs in 0.7% of tracheostomy patients with a mortality of 50-70%.1 Seventy-five percent of patients with a TIAF will present within the first three weeks of surgery and 50% of patients will present with a sentinel bleed that briefly resolves.1 Key elements of a history and exam that should raise a provider's concern for this diagnosis include a recent tracheostomy (within the last 4 weeks), a percutaneous tracheostomy, prior radiation, chronic steroid use, a neck or chest deformity or a sentinel bleed.2 Survival from a TIAF hinges upon emergent, operative repair by an otolaryngologist and cardiothoracic surgeon. Cuff hyperinflation and the Utley Maneuver are critical bedside interventions to temporize this massive bleed and stabilize the patient for definitive, operative repair. By the end of this simulation, learners will be able to: 1) perform a focused history and physical exam on any patient who presents with bleeding from the tracheostomy site, 2) describe the differential diagnosis of bleeding from a tracheostomy site, including a TIAF, 3) demonstrate the stepwise management of bleeding from a suspected TIAF, including cuff hyperinflation and the Utley Maneuver, 4) verify that definitive airway control via endotracheal intubation is only feasible in the tracheostomy patient when it is clear, upon history and exam, that the patient can be intubated from above, 5) demonstrate additional critical actions in the management of a patient with a TIAF, including early consultation with otolaryngology and cardiothoracic surgery as well as emergent blood transfusion and activation of a massive transfusion protocol. This case was written with a modified, low-fidelity manikin, traditionally used for training in nasogastric tube placement and tracheostomy care. We modified this manikin to simulate a hemorrhage from the tracheostomy site.3 The patient in our case had a history of laryngeal cancer, and thus we occluded his larynx for this simulation. As a result of this obstruction, he was unable to be intubated from above. We provided confederates, a bedside nurse and family member, to assist the learners throughout the case. We also utilized a simulation technician to operate dynamic vital signs on a simulated cardiac monitor. It would be technically challenging to adapt this case to a high-fidelity simulator due to potential for damage of the internal electrical elements by the large amount of artificial blood from the tracheostomy tube. However, a mechanical pump provided a useful means of active bleeding in this low-fidelity manikin. We provided a pre- and post-simulation questionnaire for the 33 emergency medicine residents who participated in this simulation. There were 11 residents from each of the PGY-1, PGY-2 and PGY-3 year-groups. Thirty-two residents (97%) completed the pre-survey and 33 residents (100%) completed the post-survey. For our questions, we used a 5-point Likert Scale to assess a resident's knowledge of the learning objectives within this simulation. Responses from our pre- and post- survey indicated a significant improvement in knowledge about a tracheoinnominate artery fistula as well as the general management of tracheostomy complications in the emergency department. This simulation is a useful educational tool for instructing emergency medicine residents on optimal management of tracheostomy emergencies such as a TIAF. The interprofessional teaching by an emergency medicine attending and mid-level (PGY-3) otolaryngology resident allowed for a richer and more detailed discussion during the debriefing. Throughout the case, the emergency medicine attending played the role of a bedside nurse and offered supportive, clinical cues when bleeding recurred. The otolaryngology resident played the role of a family member and offered helpful cues during the history and exam portion of the case. Following the case, both content experts provided useful clinical insight during the debriefing. If staffing availability permits, it might be advantageous to use additional simulation-trained personnel to play the roles of the nurse and family member, thus allowing the emergency medicine attending and otolaryngology content experts to simply view the case from the control room and perform the debriefing. Tracheostomy, surgical airway, tracheoinnominate artery fistula, bleeding from tracheostomy site, complications with tracheostomies, hemorrhagic shock.

Modified Manikin for Tracheoinnominate Artery Fistula.

This simulator is designed to instruct emergency medicine residents in tracheostomy training that involves bleeding from the tracheostomy site. Any resident, fellow, or attending physician who cares for patients with complications from their tracheostomy might benefit from this innovation. The emergency medicine provider must maintain proficiency in caring for patients with complications from their tracheostomy. In the United States, over 110,000 patients receive tracheostomies per year.1 A rare but catastrophic complication of tracheostomies, usually within the first month of placement, is a tracheoinnominate artery fistula (TIAF). This complication occurs in 0.7% of tracheostomy patients and carries a 50-70% mortality.1,2 We modified a low-fidelity tracheostomy manikin to instruct learners in the stepwise management of hemorrhage from a TIAF. By the end of this educational session, learners will be able to:Perform a focused history and physical exam on any patient who presents with bleeding from the tracheostomy site.Describe the differential diagnosis of bleeding from a tracheostomy site, including a TIAF.Demonstrate the stepwise management of bleeding from a suspected TIAF, including cuff hyperinflation and the Utley Maneuver.Verify that definitive airway control via endotracheal intubation is only feasible in the tracheostomy patient when it is clear, upon history and exam, that the patient can be intubated from above.Demonstrate additional critical actions in the management of a patient with a TIAF, including early consultation with otolaryngology and cardiothoracic surgery as well as emergent blood transfusion and activation of a massive transfusion protocol. This modified manikin is a useful training tool for any healthcare provider who is involved in the treatment and stabilization of a variety of tracheostomy emergencies, from bleeding to infection to obstruction or dislodgement. Our case was presented on two separate occasions, to otolaryngology interns (PGY-1), and emergency medicine residents (PGY 1-3). It involved the care of a patient with a sentinel bleed and subsequent hemorrhage from a tracheoinnominate artery fistula (TIAF). This low-fidelity tracheostomy manikin provides the ideal platform for any complex, tracheostomy case, particularly where ongoing bleeding from the tracheostomy site might permanently damage the electrical circuitry of a high-fidelity model. We initially fashioned this modified manikin for tracheostomy training during a simulation "boot camp" for otolaryngology PGY-1 residents. Our use of this modified manikin for tracheostomy training was a useful teaching tool during our otolaryngology intern "boot camp." As a result, we organized a subsequent simulation training session with our PGY 1-3 emergency medicine residents to provide similar instruction in management of a TIAF. We provided a pre- and a post-simulation survey for the 33 emergency medicine residents who participated in the TIAF simulation with our modified tracheostomy manikin. There were 11 residents from each of the PGY-1, PGY-2, and PGY-3 year-groups. Thirty-two residents (97%) completed the pre-simulation survey, and 33 residents (100%) completed the post-simulation survey. We used a 6-point Likert Scale from "strongly agree" to "strongly disagree" to assess a resident's knowledge of multiple learning objectives within this simulation. The pre- and post-simulation survey supported this simulation and manikin innovation as a useful teaching tool for tracheostomy emergencies such as a TIAF. This was a useful innovation for emergency provider training in the recognition and management of a TIAF, a rare but emergent tracheostomy complication. In addition to this bleeding complication, this innovation might be useful for a variety of tracheostomy emergencies such as site infection, obstruction, and tube dislodgement. We highly recommend the involvement of both an emergency medicine and otolaryngology content expert in the design and debriefing of tracheostomy cases with this modified manikin. In our experience, a facilitated debriefing by an experienced clinician and educator from both fields provided a diverse perspective for challenging cases such as bleeding from a TIAF. Difficult airway, tracheostomy, tracheoinnominate fistula, hemorrhagic shock, tracheostomy complications, Utley Maneuver.

Outcomes of early reoperation in severe pancreatic fistula and/or haemorrhage after pancreaticoduodenectomy

Although advances in multidisciplinary management reduce the mortality after pancreaticoduodenectomy (PD) from medical complications, postoperative pancreatic fistula (POPF) and/or postpancreatectomy haemorrhage (PPH) still remain as common morbidities and main causes of mortality. The morbidity of POPF and/or PPH after PD in our centre, Yangon Specialty Hospital, is 18-30% per year. And there are still ongoing disputes regarding management of POPF and/or PPH after PD. It is a hospital based prospective descriptive study carried out between 2018 January and 2020 April in surgical units at Yangon General Hospital, New Yangon General Hospital and our centre. Total 28 reoperated patients with POPF and/or PPH patients after PD were included in the study. The indications for reoperation in this study were patients with SIRS together with drain amount more than 300 ml/day and/or blood in drain/ NGT with Hb drop ≥ 3 g% or sentinel bleed. Preoperative CECT scan was done if condition was favorable. In this study, demographic distribution, proportion of reoperation, timing of reoperation, types of procedure were also recorded while outcomes of reoperation was emphasized in this eposter. There were 56 patients who suffered from POPF and/or PPH after PD for periampullary carcinoma during this study period. Although reoperation was advised to 34 patients, who met the indications for reoperation, six of them declined operation for various reasons. Therefore, total 28 patients were reoperated (50%). Fig. 1 showed the intraoperative findings of POPF and PPH patient. Median timing of reoperation was 9 days (2-25 days) and 71% were reoperated within 10 days. While external tube wirsungosotmy (Fig. 2) was performed in majority of POPF cases as a damage control surgery, PPH patients ended up with mainly laparotomy and GDA ligation for arrest of haemorrhage because of lack of interventional radiology (IR) support at present. Among reoperated patients, 14 patients (50%) survived and 14 patients (50%) expired. Therefore, overall in-hospital mortality was 50% in reoperated cases. The main cause was multi-organ failure due to severe sepsis. According to the Fig. 3, in-hospital mortality rate of POPF was 16% and that of PPH was 66% while that of POPF and PPH was 80% in this study. Gangl et al. (2011) [1] reported that the combination of pancreatic fistula and severe hemorrhage was a strong predictor of postoperative mortality (relative risk (RR), 22.75). And Tamijmarane et al. (2006) [2] pointed out that patients themselves are in such a moribund condition that their associated mortality rate ranges between 38 and 50%. In addition, it was surprisingly found that all six patients, who needed reoperation, died with conservative management in this study. It is found that reoperation is necessary in patients when it is indicated i.e. mainly clinical based. Early reoperation and damage control surgery is found to have better outcomes in especially POPF patients before organ failure or haemorrhage supervenes. And it is hard to say the accurate timing of reoperation and optimal procedures because this study has some limitations like small sample size, and limited resources for multidisciplinary management. Therefore, further study with larger sample size and optimal resources and management will be necessary for better and more significant results. Showing intraoperative findings of POPF and PPH. Showing method of external tube Wirsungostomy insertion. Outcomes of reoperative management.

Delayed Postoperative Hemorrhage Complicating Major Supramesocolic Surgery Management and Outcomes.

The place of surgery and interventional radiology in the management of delayed (> 24h) hemorrhage (DHR) complicating supramesocolic surgery is still to define. The aim of the study was to evaluate outcomes of DHR using a combined multimodal strategy. Between 2005 and 2019, 57 patients (median age 64years) experienced 86 DHR episodes after pancreatic resection (n = 26), liver transplantation (n = 24) and other (n = 7). Hemodynamically stable patients underwent computed tomography evaluation followed by interventional radiology (IR) treatment (stenting and/or embolization) or surveillance. Hemodynamically unstable patients were offered upfront surgery. Failure to identify the leak was managed by either prophylactic stenting/embolization of the most likely bleeding source or surveillance. Mortality was 32% (n = 18). Bleeding recurrence occurred in 22 patients (39%) and was multiple in 7 (12%). Sentinel bleeding was recorded in 77 (81%) of episodes, and the bleeding source could not be identified in 26 (30%). Failure to control bleeding was recorded in 9 (28%) of 32 episodes managed by surgery and 4 (11%) of 41 episodes managed by IR (p = 0.14). Recurrence was similar after stenting and embolization (n = 4/18, 22% vs n = 8/26, 31%, p = 0.75) of the bleeding source. Recurrence was significantly lower after prophylactic IR management than surveillance of an unidentified bleeding source (n = 2/10, 20% vs. n = 11/16, 69%, p = 0.042). IR management should be favored for the treatment of DHR in hemodynamically stable patients. Prophylactic IR management of an unidentified leak decreases recurrence risks.

Before sentinel bleeding: early prediction of postpancreatectomy hemorrhage (PPH) with a CT-based scoring system.

Clinically significant pancreatic fistula (POPF) has been established as a well-known risk factor for late and severe postpancreatectomy hemorrhage after pancreaticoduodenectomy (PD) (postpancreatectomy pancreatic fistula-associated hemorrhage [PPFH]). Our aim was to assess whether contrast-enhanced CT scan after PD is an effective tool for early prediction of PPFH. From a prospectively acquired database, all consecutive patients who underwent PD between January 2013 and May 2019 were identified; within this database, all patients who were evaluated, for clinical suspicion of POPF, with at least one contrast-enhanced CT scan examination, were enrolled in this retrospective study. The selected CT findings included perianastomotic fluid collections and air bubbles; pancreaticojejunostomy (PJ) was analyzed in terms of dehiscence and defect. One hundred seventy-eight out of 953 PD patients (18.7%) suffered from clinically significant POPF; after exclusions, 166 patients were enrolled. Among this subset, 33 patients (19.9%) had at least one PPFH episode. In multivariable analysis, PPFH was associated with postoperative CT evidence of fluid collections (p = 0.046), air bubbles (p = 0.046), and posterior PJ defect (p < 0.001). Based on these findings, a practical 4-point prediction score was developed (AUC: 0.904, Se: 76%, Sp: 93.8%): patients with a score ≥ 3 demonstrated a significantly higher risk of PPFH development (OR = 45.6, 95% CI: 13.0-159.3). Postoperative CT scan permits early stratification of PPFH risk, thus providing an actual aid for patients' management. • Postpancreatectomy hemorrhage (PPH) is a dramatic, clinically unpredictable occurrence. • After pancreaticoduodenectomy (PD), early identification of posterior pancreaticojejunostomy defect, perianastomotic air bubbles, and retroperitoneal fluid collections enables effective PPH risk stratification by means of a practical CT-based 4-point scoring system. • CT scan after PD allows a paradigm shift in the management PPH, from a conventional "wait and see" approach, to a more proactive one that relies on early anticipation and timely prevention.

AORTOESOPHAGEAL FISTULA PRESENTING AS HEMATEMESIS AFTER UPPER ENDOSCOPY

SESSION TITLE: Medical Student/Resident Critical Care Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Aortoesophageal fistulas (AEFs) are a rare and deadly cause of upper gastrointestinal bleeds. Prior repair of the thoracic aorta, primary aortic aneurysms, foreign body ingestion and thoracic cancer account for more than 90% of AEFs. Here we present the case of a patient developing AEF after a diagnostic esophagogastroduodenoscopy (EGD). CASE PRESENTATION: A 72-year-old male smoker with a history lung cancer status post right lobectomy presented with months of progressive solid dysphagia. In the past months he underwent two EGDs with balloon dilation of esophageal strictures, of which the most recent one was complicated by a distal esophageal perforation requiring an esophageal stent. Weeks after stent removal his dysphagia returned, prompting a repeat EGD to obtain biopsies of his stricture [Figure 1A-B]. The post-operative course was complicated by a small episode of hematemesis, for which the patient was offered admission for observation but declined. After eating his first meal at home, the patient had a second episode of hematemesis which prompted him to present to the emergency department. On admission, the patient was noted to have hematemesis necessitating a rapid response activation. He underwent emergent endotracheal intubation for airway protection and was started on pantoprazole and octreotide infusions. A massive transfusion protocol was initiated, and the patient was transferred to the intensive care unit where he was started on multiple vasopressors for his hypovolemic shock. A stat computed tomography angiogram (CTA) of the chest was suspicious for an underlying aorto-esophageal fistula [Figure 2A-C]. Thoracic surgery was consulted and given the patient’s age and complexity of the procedure; he was deemed a poor surgical candidate. Ultimately the patient’s family decided to pursue comfort care and the patient passed shortly thereafter. DISCUSSION: The presentation of AEF is characterized by a triad of midthoracic pain, sentinel arterial hemorrhage, and massive hemorrhage after a symptom-free interval. While initial clot formation tamponades the fistula, GI contents rapidly weaken this clot. Evaluation for AEF should done with a CTA-Chest as it has been found to be more sensitive than EGD. Initial therapy should focus on achieving hemodynamic stability via thoracic endovascular aneurysm repair or aortic graft replacement. AEF outcomes are improved when the esophageal pathology can be addressed with esophagectomy, stenting, or fistula repair, and with use of post-operative broad-spectrum antibiotics. Prompt surgical intervention increases one-year survival up to 50%. CONCLUSIONS: AEF should be included in the differential of hematemesis after instrumentation for an EGD. Limited time exists between the herald bleed and massive hemorrhage to confirm the diagnosis and plan for a surgical approach. CTA-Chest should be obtained first, followed by an EGD when imaging is inconclusive. Reference #1: Takeno S, Ishii H, Nanashima A, Nakamura K. Aortoesophageal fistula: review of trends in the last decade. Surg Today. December 2019:1-9. Reference #2: Uittenbogaart M, Sosef MN, van Bastelaar J. Sentinel bleeding as a sign of gastroaortic fistula formation after oesophageal surgery. Case Rep Surg. 2014;2014:614312. Reference #3: Vu QDM, Menias CO, Bhalla S, Peterson C, Wang LL, Balfe DM. Aortoenteric fistulas: CT features and potential mimics. Radiographics. 2009;29(1):197-209. DISCLOSURES: No relevant relationships by Hareen Chela, source=Web Response No relevant relationships by Ethan Karle, source=Web Response No relevant relationships by Adam Letvin, source=Web Response No relevant relationships by Tarang Patel, source=Web Response No relevant relationships by Shyam Shankar, source=Web Response

Outcome of interventional radiology for delayed postoperative hemorrhage in hepatobiliary and pancreatic surgery.

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. Overall, 4220 patients underwent surgery for hepatobiliary and pancreatic diseases. Delayed postoperative hemorrhage (observed more than 24h 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. 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 19days (range: 5-252days). 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). 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.

A RARE CASE OF TRACHEOINOMINATE FISTULA

SESSION TITLE: Wednesday Fellows Case Report Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Within 2-4 weeks after placement, a tip or cuff of a tracheostomy tube may erode into the anterior wall of the trachea, resulting in a morbid and often fatal outcome. We present a rare case of tracheoinnominate fistula (TIF) after a tracheostomy. CASE PRESENTATION: A 51-year-old woman with non-ischemic cardiomyopathy after a complicated ascending aortic aneurysm status post orthotopic heart transplant presented with gradual onset of dyspnea and facial swelling. CTA of the chest revealed an aneurysm of the innominate artery measuring 3.7 x 3.4 cm and a significant subglottic tracheal stenosis. A large multinodular goiter was noted on ultrasound. Due to her diffuse facial swelling, exophthalmos, and engorged veins, her culprit diagnosis was thought to be SVC syndrome. After a subsequent CT venography, she underwent stenting of the right innominate vein. However, her symptoms persist, and as a result of her worsening stridor, the patient was intubated. She then underwent a tracheostomy and partial thyroidectomy. Twelve days post tracheostomy, patient had a self-resolving episode of non-massive hemoptysis. Given her innominate artery aneurysm, a sentinel bleed for a tracheoinnominate fistula was suspected. Her uncuffed tracheostomy tube was quickly exchanged for a cuffed one, and the balloon was hyperinflated. After a temporary tamponade, she was emergently taken to the operating room for an innominate artery ligation and a carotid-to-carotid bypass. DISCUSSION: Development of tracheoinnominate fistula is a rare complication of tracheostomy occurring in only 1% with nearly a 90% mortality. When faced with a massive hemoptysis or even a sentinel bleed, one must have a high index of suspicion for TIF in a patient with a recent tracheotomy placement. Common risk factors include low tracheostomy, high innominate artery, cuff overinflation, infection, and immunosuppressed state. Our patient unfortunately had a perfect storm—a history of a complicated ascending aortic aneurysm involving the innominate artery, on chronic immunosuppressants, and subglottic tracheal stenosis requiring a low tracheostomy. To minimize exsanguination, suspect TIF and quickly tamponade the anterior wall of the tracheal with one’s finger or overinflating the balloon. CONCLUSIONS: Tracheoinnominate fistula, although more rare since the advent of low-pressure tracheostomy tubes, remains a highly lethal complication of tracheostomy. Successful management relies on early diagnosis and prompt management. Reference #1: 1. Allan JS, Wright CD: Tracheoinnominate fistula: Diagnosis and management. Chest Surg Clin North Am 13:331-341, 2003 GrilloCG: Tacheal fistulato barchiocephalic artery,inGrilloCG (ed): Surgery of the Trachea and Bronchi. Hamilton, Ontario, BC Decker, Ch. 13, 2003, pp 1-9 Reference #2: 2. GrilloCG: Tacheal fistulato barchiocephalic artery,inGrilloCG (ed): Surgery of the Trachea and Bronchi. Hamilton, Ontario, BC Decker, Ch. 13, 2003, pp 1-9 Reference #3: 3. Technique for Managing Tracheo-Innominate Artery Fistula, Gorav Ailawadi, MD DISCLOSURES: No relevant relationships by Bindu Akkanti, source=Web Response No relevant relationships by Kha Dinh, source=Web Response No relevant relationships by Samim Jafri, source=Web Response

1323 Hemosuccus Pancreaticus Secondary to Hepatic Artery Pseudoaneurysm Presenting as Acute Gastrointestinal Bleed

INTRODUCTION: Hepatic Artery Psuedoaneurysms (HAPs) are typically caused by iatrogenic injury from instrumentation during invasive procedures or trauma. Psuedoaneurysms are described as a disruption/tear through all three layers of the arterial wall, with a fibrous capsule intact. Detection of HAP is important, as the rupture rate is around 76%. CASE DESCRIPTION/METHODS: A 77-year-old male with PMH of chronic pancreatitis with pseudocyst formation and necrotizing pancreatitis presented to the emergency department with 36 hours of black stools and diffuse abdominal pain. Admission labs showed a hemoglobin of 11.4 gm/dl, AST of 113 U/L, ALT 197 U/L, lipase 535 U/L. Given his past history and acute transaminitis, CT abdomen/pelvis was completed and showed 1.7 × 1.5 cm pseudoaneurysm of the common hepatic artery (Figure 1). Melena progressed to frank bright blood in the stools. Hemoglobin dropped to 9.7 gm/dl. Given these findings, vascular surgery and gastroenterology were consulted. He was started on Protonix and Octreotide and over the next two days, his hemoglobin stabilized but continued to have melanotic stools. Patient underwent esophagogastroduodenoscopy (EGD) which was negative for bleeding. Given the HAP and lack of findings during the EGD, he was taken for Hepatic artery stenting (Figure 2). Plavix was initiated post stenting. Post stenting his melena resolved. Patient was sent home with follow up as outpatient and CT scan in 1 month. CT abdomen completed 1 month after stent placement showed a patent stent within the common hepatic artery without an extravasation of contrast into previous pseudoaneurysm. DISCUSSION: This case illustrates the importance of keeping a broad differential in a patient with complex past gastrointestinal history, presenting with a common chief complaint. In the case presented, it is hypothesized that the origin of his HAP was secondary to his chronic pancreatitis leading to hemosuccus pancreaticus resulting in acute gastrointestinal bleed. This case was unique in that most hemosuccus pancreaticus involve splenic artery pseudoaneurysm instead of HAP. Overall, identification of HAP is important given the high risk of rupture and mortality rate ranging from 25-70%. Definitive treatment surgically or endovascular is necessary for all HAPs. As presented in the case, diagnosis of HAP is critical as it can be the source of a sentinel bleed in patients presenting with an acute gastrointestinal bleed and should be considered in the differential for all gastrointestinal bleeds.

Systematic review of the incidence, presentation and management of gastroduodenal artery pseudoaneurysm after pancreatic resection.

BackgroundGastroduodenal artery (GDA) pseudoaneurysm is a serious complication following pancreatic resection, associated with high morbidity and mortality rates. This review aimed to report the incidence of GDA pseudoaneurysm after pancreatic surgery, and describe clinical presentation and management.MethodsMEDLINE and Embase were searched systematically for clinical studies evaluating postoperative GDA pseudoaneurysm. Incidence was calculated by dividing total number of GDA pseudoaneurysms by the total number of pancreatic operations. Additional qualitative data related to GDA pseudoaneurysm presentation and management following pancreatic resection were extracted and reviewed from individual reports.ResultsNine studies were selected for systematic review involving 4227 pancreatic operations with 55 GDA pseudoaneurysms, with a reported incidence of 1·3 (range 0·2–8·3) per cent. Additional data were extracted from 39 individual examples of GDA pseudoaneurysm from 14 studies. The median time for haemorrhage after surgery was at 15 (range 4–210) days. A preceding complication in the postoperative period was documented in four of 21 patients (67 per cent), and sentinel bleeding was observed in 14 of 20 patients (70 per cent). Postoperative complications after pseudoaneurysm management occurred in two‐thirds of the patients (14 of 21). The overall survival rate was 85 per cent (33 of 39).ConclusionGDA pseudoaneurysm is a rare yet serious cause of haemorrhage after pancreatic surgery, with high mortality. The majority of the patients had a preceding complication. Sentinel bleeding was an important clinical indicator.

The Sentinel Bleed

The Sentinel Bleed