Arterial reinforcement following pancreatoduodenectomy: The solution to prevent delayed hemorrhage caused by postoperative pancreatic fistula

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.

Hepatic artery protection using a polyglycolic acid sheet during pancreaticoduodenectomy: A multicenter study

“…One case that was described in our previous study was a patient on whom relaparotomy was performed for PPH after AR. Operative findings showed only small amounts of bleeding from the area of vessels protected by Neoveil 11 . In another similar case, relaparotomy was performed on a patient who developed PPH after AR, and findings showed a intact GDA stump that was protected by Neoveil, and a rupture at the base of the proper hepatic artery.…”

“…Operative findings showed only small amounts of bleeding from the area of vessels protected by Neoveil. 11 In another similar case, relaparotomy was performed on a patient who developed PPH after AR, and findings showed a intact GDA stump that was protected by Neoveil, and a rupture at the base of the proper hepatic artery. After experiencing this case, we modified our method to cover the entire hepatic artery, from the root of the proper hepatic artery to the bifurcation of the common hepatic artery.…”

“…We have found that this method of arterial reinforcement (AR) greatly reduces the incidence of PPH form the hepatic artery. In 2022, we published a single center retrospective study showing the effectiveness of AR in protecting against PPH 11 . After this encouraging result, we decided to perform a retrospective multicenter study to validate the initial findings.…”

“…In 2022, we published a single center retrospective study showing the effectiveness of AR in protecting against PPH. 11 After this encouraging result, we decided to perform a retrospective multicenter study to validate the initial findings. In this study, we analyzed the protective effect of AR in preventing PPH after PD.…”