Diagnosis and Treatment of Abdominal Arterial Bleeding After Radical Gastrectomy: a Retrospective Analysis of 1875 Consecutive Resections for Gastric Cancer

Abstract

BackgroundMassive abdominal arterial bleeding is an uncommon yet life-threatening complication of radical gastrectomy. The exact incidence and standardized management of this lethal morbidity are not known.MethodsBetween January 2003 and December 2013, data from 1875 patients undergoing radical gastrectomy with D2 or D2 plus lymphadenectomy were recorded in a prospectively designed database from a single institute. The clinical data and management of both early (within 24 h) and late (beyond 24 h) postoperative abdominal arterial hemorrhages were explored. For late bleeding patients, transcatheter arterial embolization (TAE) and re-laparotomy were compared to determine the better initial treatment option.ResultsThe overall prevalence of postoperative abdominal arterial bleeding was 1.92 % (n = 36), and related mortality was 33.3 % (n = 12). Early and late postoperative bleedings were found in 6 and 30 patients, respectively. The onset of massive arterial bleeding occurred on average postoperative day 19. The common hepatic artery and its branches were the most common bleeding source (13/36; 36.1 %). All the early bleeding patients were treated with immediate re-laparotomy. For late bleeding, patients from the TAE group had a significantly lower mortality rate than that of the patients from the surgery group (7.69 vs. 56.25 %, respectively, P = 0.008) as well as a shorter procedure time for bleeding control (2.3 ± 1.1 vs. 4.8 ± 1.7 h, respectively, P < 0.001). Four rescue reoperations were performed for TAE failures; the salvage rate was 50 % (2/4). Ten patients developed massive re-bleeding after initial successful hemostasis by either TAE (5/13) or open surgery (5/16). Three out of the 10 re-bleeding patients died of disseminated intravascular coagulation (DIC), while the other 7 recovered eventually by repeated TAE and/or surgery.ConclusionAbdominal arterial bleeding following radical gastrectomy tends to occur during the later phase after surgery, with further complications such as abdominal infection and fistula(s). For late bleeding, TAE can be considered as the first-line treatment when possible.Electronic supplementary materialThe online version of this article (doi:10.1007/s11605-015-3049-z) contains supplementary material, which is available to authorized users.

Management of postoperative complications of lymphadenectomy

“…The overall postoperative arterial hemorrhage rate was 1.92%, with a relatively high mortality rate of 33.3%. It is mostly caused by abdominal arterial bleeding, mainly from branches of the celiac trunk, the common hepatic artery and its branches and splenic artery (31). Rupture of abdominal arteries can provoke not only massive abdominal bleeding but also intraluminal bleeding.…”

Transcatheter Arterial Embolization for the treatment of upper gastrointestinal bleeding

“…Recent research suggetsed that TAE is a safe treatment method for gastrointestinal bleeding. Authors have reported satisfactory results of TAE compared to surgery for treatment of bleeding after gastric cancer resection, duodenal bleeding, severe bleeding of upper gastrointestinal tumors and bleeding gastroduodenal ulcers [6][7][8][9][10].…”

Interventional radiology for post-gastrectomy complications

“…1). 6,7 The hemorrhage may be caused by a weakened arterial wall due to arterial skeletonization (dissection of the arterial fibrous sheath or adventitial layer) after aggressive lymphadenectomy. 8 Abdominal abscess, which will be discussed later in this article, can be a cause of bleeding at period several days after surgery by erosion of adjacent vessels.…”

“…3,7 In the late postoperative period, however, angiography and transarterial embolization (TAE) should be considered as first-line treatment, since the bleeding site is difficult to find surgically due to adhesions, inflammatory reactions, and friability of postoperative tissues. 6,7 Furthermore, TAE is a less invasive approach, irrespective of tissue adhesions and friability caused by primary surgery.…”