Management of Delayed Postoperative Hemorrhage After Pancreaticoduodenectomy

Abstract

To determine whether interventional radiology (IR) or laparotomy (LAP) is the best management of delayed postoperative hemorrhage (DPH) after pancreaticoduodenectomy. Data Source:We undertook an electronic search of MEDLINE and selected for analysis only original articles published between January 1, 1990, and December 31, 2007.Study Selection: Two of us independently selected studies reporting on clinical presentation and incidence of postoperative DPH and the following outcomes: complete hemostasis, morbidity, and mortality.Data Extraction: Two of us independently performed data extraction. Data were entered and analyzed by means of dedicated software from The Cochrane Collaboration. A random-effects meta-analytical technique was used for analysis.Data Synthesis: One hundred sixty-three cases of DPH after pancreaticoduodenectomy were identified from the literature. The incidence of DPH after pancreaticoduodenectomy was 3.9%. Seventy-seven patients (47.2%) underwent LAP; 73 (44.8%), IR; and 13 (8%), conservative treatment. On meta-analysis comparing LAP vs IR for DPH, no significant difference was found between the 2 treatment options for complete hemostasis (73% vs 76%; P=.23), mortality (43% vs 20%; P=.14), or morbidity (77% vs 35%; P=.06). Conclusions: This meta-analysis, although based on data from small case series, is unable to demonstrate any significant difference between LAP and IR in the management of DPH after pancreaticoduodenectomy. The management of this life-threatening complication is difficult, and the appropriate treatment pathway ultimately will be decided by the clinical status of the patient and the institution preference.

Pancreatoduodenectomy - Preventing Complications

“…Post surgical bleeding complications are reported in 5-16 % [8,[11][12][13][14][15] of patients following PD and are associated with high morbidity and mortality. A number of different definitions have been used by different authors.…”

“…Delayed haemorrhage is invariably associated with a pancreatic anastomotic leakage [13][14][15][16][17] and therefore prevention of delayed haemorrhage is almost always dependent on a well done and secure pancreatic anastomosis. The various aspects on pancreatic anastomosis would be discussed in the section dealing with the preventive aspects of pancreatic anastomotic leak and fistula.…”

Role of interventional radiology in the management of complications after pancreatic surgery: a pictorial review

“…Postoperative intra-abdominal arterial haemorrhage is still one of the most serious complications, with a reported incidence between 1.5 and 15 %, and a reported mortality rate of 20-50 % [15][16][17]. Haemorrhage is defined as 'early' when occurring within 24 h after surgery, while 'late' haemorrhages occur after 24 h [30].…”

“…Transcatheter arterial embolisation has been reported to be safe and effective, with a reported success rate of 50-100 %, gaining acceptance for the treatment of intra-abdominal bleeding [15][16][17]. Once the site of bleeding has been identified, several different techniques may be used to stop bleeding and achieve haemostasis.…”

“…Although in recent years refinements in surgical technique and perioperative management have led to a reduction in perioperative mortality, the incidence of postoperative complications (including intra-abdominal abscesses and leakages [4][5][6][7][8][9], biliary complications [10][11][12][13][14] and vascular complications [15][16][17][18]) still remains high. Moreover, in case of complications, surgical re-operation is associated with a high mortality rate [1][2][3].…”