Haemorrhage following Pancreaticoduodenectomy: Risk Factors and the Importance of Sentinel Bleed

Koukoutsis, Ilias; Bellagamba, Riccardo; Morris‐Stiff, Gareth; Wickremesekera, Susrutha K.; Coldham, C.; Wigmore, Stephen J.; Mayer, A. D.; Mirza, Darius F.; Buckels, J. A. C.; Bramhall, Simon R.

doi:10.1159/000094754

Cited by 69 publications

(83 citation statements)

References 66 publications

(46 reference statements)

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“…Relatively little research has attempted to identify risk factors for thromboprophylaxis-related bleeding in general or abdominal-pelvic surgery, although a few studies have identifi ed risk factors in patients undergoing gastric cancer surgery, 85 pancreaticoduodenectomy, 86 partial hepatic resection, 87 and mixed abdominal surgery ( Table 8 ). 88 In the absence of data from large, prospective, population-based observational studies, the baseline risk of bleeding can be derived from the control (placebo or no pharmacologic prophylaxis) groups in randomized trials.…”

Section: Baseline Risk Risk Factors and Risk Stratifi Cation For Mamentioning

confidence: 99%

Prevention of VTE in Nonorthopedic Surgical Patients

Gould

García

Wren

et al. 2012

Chest

1,784

744

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(Grade 2C) prophylaxis be used other than early ambulation. For patients at low risk for VTE ( ‫ف‬ 1.5%), we suggest mechanical prophylaxis, preferably with intermittent pneumatic compression (IPC), over no prophylaxis (Grade 2C). For patients at moderate risk for VTE ( ‫ف‬ 3%) who are not at high risk for major bleeding complications, we suggest low-molecular-weight heparin (LMWH) (Grade 2B), low-dose unfractionated heparin (Grade 2B), or mechanical prophylaxis with IPC (Grade 2C) over no prophylaxis. For patients at high risk for VTE ( ‫ف‬ 6%) who are not at high risk for major bleeding complications, we recommend pharmacologic prophylaxis with LMWH (Grade 1B) or low-dose unfractionated heparin (Grade 1B) over no prophylaxis. In these patients, we suggest adding mechanical prophylaxis with elastic stockings or IPC to pharmacologic prophylaxis (Grade 2C). For patients at high risk for VTE undergoing abdominal or pelvic surgery for cancer, we recommend extended-duration, postoperative, pharmacologic prophylaxis (4 weeks) with LMWH over limited-duration prophylaxis (Grade 1B). For patients at moderate to high risk for VTE who are at high risk for major bleeding complications or those in whom the consequences of bleeding are believed to be particularly severe, we suggest use of mechanical prophylaxis, preferably with IPC, over no prophylaxis until the risk of bleeding diminishes and pharmacologic prophylaxis may be initiated (Grade 2C). For patients in all risk groups, we suggest that an inferior vena cava fi lter not be used for primary VTE prevention (Grade 2C) and that surveillance with venous compression ultrasonography should not be performed (Grade 2C). We developed similar recommendations for other nonorthopedic surgical populations. Conclusions: Optimal thromboprophylaxis in nonorthopedic surgical patients will consider the risks of VTE and bleeding complications as well as the values and preferences of individual patients. CHEST 2012; 141(2)(Suppl):e227S-e277SAbbreviations: CABG 5 coronary artery bypass graft; ES 5 elastic stockings; ICH 5 intracranial hemorrhage; IPC 5 intermittent pneumatic compression; IVC 5 inferior vena cava; LDUH 5 low-dose unfractionated heparin; LMWH 5 low-molecular-weight heparin; PE 5 pulmonary embolism; QALY 5 quality-adjusted life year; RR 5 risk ratio; VCU 5 venous compression ultrasonography

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Section: Baseline Risk Risk Factors and Risk Stratifi Cation For Mamentioning

confidence: 99%

Prevention of VTE in Nonorthopedic Surgical Patients

Gould

García

Wren

et al. 2012

Chest

1,784

744

View full text Add to dashboard Cite

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“…Late post-pancreaticoduodenectomy bleeding is often associated with anastomotic leakage, especially from pancreatic anastomosis, and intra-abdominal infection [1,2,3, 9, 11, 23, 24]. Approximately two thirds of the reported cases of late arterial post-pancreaticoduodenectomy bleeding are found to have an underlying fluid collection or anastomotic leakage, with a pseudoaneurysm formation identified in approximately one third of the cases [3, 10].…”

Section: Discussionmentioning

confidence: 99%

“…Approximately two thirds of the reported cases of late arterial post-pancreaticoduodenectomy bleeding are found to have an underlying fluid collection or anastomotic leakage, with a pseudoaneurysm formation identified in approximately one third of the cases [3, 10]. It is hypothesized that late post-pancreaticoduodenectomy bleeding might be caused by erosion of the vasculature resulting from intra-abdominal contamination of enteric, pancreatic or bile juice in the area adjacent to the surgical anastomosis [2, 3, 9, 11, 23, 24]. Surgery has always been the treatment of choice for late post-pancreaticoduodenectomy bleeding [10, 25, 26].…”

Section: Discussionmentioning

confidence: 99%

Risk Factors for Post-Pancreaticoduodenectomy Bleeding and Finding an Innovative Approach to Treatment

et al. 2009

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Background: This study is to determine the risk factors and outcome for post-pancreaticoduodenectomy bleeding, and to assess the roles of surgery and intravascular intervention in its management. Methods: Post-pancreaticoduodenectomy data of 628 patients were analyzed with regards to post-pancreaticoduodenectomy bleeding. Results: Post-pancreaticoduodenectomy bleeding occurred in 58 patients (9.2%) and led to death in 23 patients. Pancreatic leakage and intra-abdominal abscess were independent risk factors for both extraluminal and intraluminal post-pancreaticoduodenectomy bleeding. The most common source of bleeding was the gastroduodenal artery (n = 9, 24.3%), and 8 of these patients (88.9%) experienced gastroduodenal artery bleeding in late post-pancreaticoduodenectomy bleeding. Hemostasis for post-pancreaticoduodenectomy bleeding was achieved by surgery in 22 patients (78.6%) and intravascular intervention in 7 patients (58.3%). Transarterial embolization for gastroduodenal artery bleeding did not deteriorate liver function in most patients except for 1 who died of hepatic failure. Conclusions: The placement of metallic clips on the gastroduodenal artery stump during a pancreaticoduodenectomy is helpful in identifying overlooked intermittent sentinel bleeding during angiography. Transarterial embolization for gastroduodenal artery bleeding could not guarantee against hepatic failure. The intravascular placement of a covered stent is the preferred procedure to avoid the complete interruption of arterial blood supply to the liver.

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“…Although the prevalence of surgical mortality of pancreaticoduodenectomy (PD) has recently fallen to acceptable levels (0–5%) [1,2,3,4,5,6,7,8,9,10], the prevalence of mortality can reach 11–60% [10,11,12,13,14,15] if postoperative arterial bleeding occurs. Post-PD arterial bleeding usually happens late (>5 days postoperatively).…”

Section: Introductionmentioning

confidence: 99%