The role of interventional radiology in the management of surgical complications after pancreatoduodenectomy

Pandanaboyana, Sanjay; Kellner, Maximiliane; Tait, Iain S.

doi:10.1111/j.1477-2574.2012.00545.x

Cited by 58 publications

(49 citation statements)

References 17 publications

(39 reference statements)

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“…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.…”

Section: Discussionsupporting

confidence: 75%

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

Nizri¹

2014

J Vasc Med Surg

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BackgroundPancreatic resection and especially pancreaticoduodenectomy (PD) is considered a complex operation, previously notorious for high perioperative morbidity and mortality rates. However, while the perioperative mortality of PD was over 15% in the 70's, it is now days less than 4% [1][2][3][4][5][6][7]. One of the most important reasons for this improvement is the greater experience of a limited number of surgeons who perform the procedure on a regular basis in high-volume referral centers [8][9][10][11]. Combined pancreatic resection and vascular reconstruction prevalence is rising. As expected, these patients have a higher morbidity and mortality rate in comparison to conventional PD (39.9% vs.33.3% and 5.7% vs.2.9%, respectively) [12].In spite of the impressive progress made in recent years in perioperative morbidity and mortality, a pancreatic fistula as a postoperative complication occurs in as high as 22% of cases [13]. Pancreatic fistulas can lead to sepsis and hemorrhage if not adequately drained. These complications are associated with mortality of 20 to 40%, prolonged hospitalization, and increased hospital expenses [14].Post pancreatectomy hemorrhage (PPH) is a term used for all bleeding episodes post pancreatic surgery. It is further divided according to the time of onset post operatively (delayed: >24 hrs postoperatively), location (intra/extraluminal, anastomotic origin) and severity of bleeding (severe PPH defined as hemoglobin drop>3 gr/ dl, hemodynamic instability or need for intervention) [15]. Prevalence of PPH is 5.5%, equally distributed among different indications for surgery (malignancies, borderline tumors, and focal pancreatitis). In an era of increased number of PD with vascular reconstruction, it is expected that the incidence of PPH will rise. In recent years an objective, universally accepted definition and clinical grading of PPH is adopted according to the International Study Group on Pancreatic surgery (ISGPS) [15].PPH-related overall mortality is 16-20% and raises to about 50% among the subgroup of DPPH secondary to pseudoaneurysm (PSA) or vascular erosion [16]. PSA exists when a normal arterial wall is replaced by fibrous tissue due to mechanical (iatrogenic) or chemical (by pancreatic juice) injury. This PSA may further cause a life-threatening bleeding.Clearly, some of the improvement in overall mortality after PD may be attributed to the post-operative management of complications. In this aspect, the considerable advances in invasive radiological techniques enable control of DPPH and reduce the need for re-laparotomy with its significant sequela [15].This study describes our experience in the management of DPPH with focus on risk factors and management. AbstractBackground: Delayed Post Pancreatectomy Hemorrhage (DPPH) is a devastating complication of pancreatic surgery, with a mortality rate approaching 50%. Clinical predictors and an effective management modality could improve patient outcome, but currently are not fully established.

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Section: Discussionsupporting

confidence: 75%

“…This male tendency had not been previously reported though higher male ratio is found in previous series [4,19,22]. However, in light of the small sample size, this finding may be a sampling error.…”

Section: Discussioncontrasting

confidence: 46%

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

Nizri¹

2014

J Vasc Med Surg

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“…For these reasons some authors have suggested that releasing a stent-graft into the hepatic artery, excluding the GDA stump, should be considered as a first-line procedure (9,75). According to some reports, covered stent-grafts are associated with a diminished risk of recurrent hemorrhage when compared to selective embolization (57,76). On the other hand, this technically challenging, especially in cases of difficult anatomy (9,27,52,72).…”

Section: Stent-graftsmentioning

confidence: 99%

Bleeding complications after pancreatic surgery: interventional radiology management

2019

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Surgical intervention in the pancreas region is complex and carries the risk of complications, also of vascular nature. Bleeding after pancreatic surgery is rare but characterized by high mortality. This review reports epidemiology, classification, diagnosis and treatment strategies of hemorrhage occurring after pancreatic surgery, focusing on the techniques, roles and outcomes of interventional radiology (IR) in this setting. We then describe the roles and techniques of IR in the treatment of other less common types of vascular complications after pancreatic surgery, such as portal vein (PV) stenosis, portal hypertension and bleeding of varices.

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“…Interventional radiology is increasingly recognized as having a significant role in the management of complications that arise after pancreatic surgery [25]. Image-guided percutaneous drainage of peripancreatic fluid collections/abscesses subsequent to a POPF was identified as the most common indication for interventional radiology after pancreatic resections (Fig.…”

Section: Interventional Techniquesmentioning

confidence: 99%

“…Catheter exchange or removal is based on clinical improvement as well as drainage catheter output, catheter malfunction or dislodgement, and evidence of persistent fluid on repeat imaging. Different studies have shown that more than 85 % of patients were managed successfully with percutaneous drainages without the need for re-operation [25,28]. Disadvantages of percutaneous drainages include the need of daily care and regular flushing of the catheter to maintain patency, as well as frequent monitoring of fluid output to determine appropriate timing for catheter removal.…”

Section: Interventional Techniquesmentioning

confidence: 99%

Diagnosis and management of postoperative pancreatic fistula

Malleo

Pulvirenti

Marchegiani

et al. 2014

Langenbecks Arch Surg

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The high incidence of POPF was accompanied by a shift from operative to non-operative management. However, the current management strategy is driven by the patient's condition and local expertise and is generally based on poor evidence. A randomized trial showed that enteral nutrition is superior to total parenteral nutrition, and pooled data of randomized trials failed to show any advantage of somatostatin analogs for accelerating fistula closure. The choice of percutaneous versus endoscopic drainage of peripancreatic collections remains arbitrary, and-when re-operation is needed-there are very few comparative data regarding local drainage with or without main pancreatic stenting as opposed to anastomotic revision or salvage re-anastomosis. The continuous development of specialist, high-volume units with appropriate resources and multidisciplinary experience in complication management might further improve the evidence and the outcomes.

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The role of interventional radiology in the management of surgical complications after pancreatoduodenectomy

Abstract: Rates of major morbidity after PD remain high. However, many significant complications (PPH, pancreatic fistula, intra-abdominal abscess) can be managed by IR, reducing the need for reoperation. Re-look surgery is still required in a small percentage (2.5%) of patients.

Cited by 58 publications

References 17 publications

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

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

Bleeding complications after pancreatic surgery: interventional radiology management

Diagnosis and management of postoperative pancreatic fistula

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