Management of Massive Arterial Hemorrhage After Pancreatobiliary Surgery: Does Embolotherapy Contribute to Successful Outcome?

Abstract

Massive arterial hemorrhage is, although unusual, a life-threatening complication of major pancreatobiliary surgery. Records of 351 patients who underwent major surgery for malignant pancreatobiliary disease were reviewed in this series. Thirteen patients (3.7%) experienced massive hemorrhage after surgery. Complete hemostasis by transcatheter arterial embolization (TAE) or re-laparotomy was achieved in five patients and one patient, respectively. However, 7 of 13 cases ended in fatality, which is a 54% mortality rate. Among six survivors, one underwent selective TAE for a pseudoaneurysm of the right hepatic artery (RHA). Three patients underwent TAE proximal to the proper hepatic artery (PHA): hepatic inflow was maintained by successful TAE of the gastroduodenal artery in two and via a well-developed subphrenic artery in one. One patient had TAE of the celiac axis for a pseudoaneurysm of the splenic artery (SPA), and hepatic inflow was maintained by the arcades around the pancreatic head. One patient who experienced a pseudoaneurysm of the RHA after left hemihepatectomy successfully underwent re-laparotomy, ligation of RHA, and creation of an ileocolic arterioportal shunt. In contrast, four of seven patients with fatal outcomes experienced hepatic infarction following TAE proximal to the PHA or injury of the common hepatic artery during angiography. One patient who underwent a major hepatectomy for hilar bile duct cancer had a recurrent hemorrhage after TAE of the gastroduodenal artery and experienced hepatic failure. In the two patients with a pseudoaneurysm of the SPA or the superior mesenteric artery, an emergency relaparotomy was required to obtain hemostasis because of worsening clinical status. Selective TAE distal to PHA or in the SPA is usually successful. TAE proximal to PHA must be restricted to cases where collateral hepatic blood flow exists. Otherwise or for a pseudoaneurysm of the superior mesenteric artery, endovascular stenting, temporary creation of an ileocolic arterioportal shunt, or vascular reconstruction by re-laparotomy is an alternative.

Delayed Post Pancreatectomy Hemorrhage: Incidence, Clinical Characteristics, Risk Factors and Management

“…Even hemodynamically unstable patients treated by IR approach had 75% survival. This was also reported by others [22,23]. Culminating evidence suggests that angiography is the preferred management option for DPPH.…”

Management of Delayed Post-Pancreaticoduodenectomy Arterial Bleeding: Interventional Radiological Treatment First

“…It has been proposed that pancreatic juice, intestinal juice and/or bile from a leaking anastomosis can erode the arterial wall (especially if the visceral artery is injured by vessel skeletonization during lymphadenectomy). In addition, anastomostic insufficiency is usually followed by localized infection and abscess formation in intra-abdominal spaces, which can further erode the arterial wall [10,18,20,23,27,30,40,42,43,44]. In the present study, all patients had intra-abdominal septic complications.…”

“…When referring to post-pancreatectomy bleeding, most authors claimed that bleeding at the early and late stage should be categorized as different entities [10,12,19,22,23,32,33]. Late bleeding after PD usually occurred >5–7 days postoperatively, with the time interval between the index operation and delayed bleeding ranging from 5 to 206 days [11,20,21,25,27,34,35,36,37]. In our study, the mean time of DPPAB was 33 days (range 7–72) postoperatively.…”

“…Sentinel bleeding has been reported to precede delayed bleeding in 25–100% of cases [10,11,12,19,23,27,35]. This probably reflects local sepsis and probable anastomotic dehiscence [20,32]. Tien et al [47] recommended angiography for every sentinel bleeding after PD.…”

“…Post-PD arterial bleeding usually happens late (>5 days postoperatively). Because of the lack of a generally accepted definition, the reported prevalence of this fatal complication varies widely (1.5–20.2%) [16,17,18,19,20,21,22]. Delayed post-pancreaticoduodenectomy arterial bleeding (DPPAB) is usually massive, with impairment of the peripheral circulation.…”