Abstract
Introduction
This review assesses the presentation, management, and outcome of delayed postpancreatectomy hemorrhage (PPH) and suggests a novel algorithm as possible standard of care.
Methods
An electronic search of Medline and Embase databases from January 1990 to February 2010 was undertaken. A random-effect meta-analysis for success rate and mortality of laparotomy vs. interventional radiology after delayed PPH was performed.
Results
Fifteen studies comprising of 248 patients with delayed PPH were included. Its incidence was of 3.3%. A sentinel bleed heralding a delayed PPH was observed in 45% of cases. Pancreatic leaks or intraabdominal abscesses were found in 62%. Interventional radiology was attempted in 41%, and laparotomy was undertaken in 49%. On meta-analysis comparing laparotomy vs. interventional radiology, no significant difference could be found in terms of complete hemostasis (76% vs. 80%; P = 0.35). A statistically significant difference favored interventional radiology vs. laparotomy in term of mortality (22% vs. 47%; P = 0.02).
Conclusions
Proper management of postoperative complications, such as pancreatic leak and intraabdominal abscess, minimizes the risk of delayed PPH. Sentinel bleeding needs to be thoroughly investigated. If a pseudoaneurysm is detected, it has to be treated by interventional angiography, in order to prevent a further delayed PPH. Early angiography and embolization or stenting is safe and should be the procedure of choice. Surgery remains a therapeutic option if no interventional radiology is available, or patients cannot be resuscitated for an interventional treatment.
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References
Trede M, Schwall G. The complications of pancreatectomy. Ann Surg 1988;207:39–47.
Tien YW, Lee PH, Yang CY, Ho MC, Chiu YF. Risk factors of massive bleeding related to pancreatic leak after pancreaticoduodenectomy. J Am Coll Surg 2005;201:554–9.
Miedema BW, Sarr MG, van Heerden JA, Nagorney DM, McIlrath DC, Ilstrup D. Complications following pancreaticoduodenectomy. Current management. Arch Surg 1992;127:945–9; discussion 949–50.
Yeo CJ, Cameron JL, Sohn TA, Lillemoe KD, Pitt HA, Talamini MA, Hruban RH, Ord SE, Sauter PK, Coleman J, Zahurak ML, Grochow LB, Abrams RA. Six hundred fifty consecutive pancreaticoduodenectomies in the 1990s: Pathology, complications, and outcomes. Annals of Surgery 1997;226:248–260.
van Berge Henegouwen MI, Allema JH, van Gulik TM, Verbeek PC, Obertop H, Gouma DJ. Delayed massive haemorrhage after pancreatic and biliary surgery. Br J Surg 1995;82:1527–31.
Rumstadt B, Schwab M, Korth P, Samman M, Trede M. Hemorrhage after pancreatoduodenectomy. Ann Surg 1998;227:236–41.
Shankar S, Russell RC. Haemorrhage in pancreatic disease. Br J Surg 1989;76:863–6.
Kleespies A, Albertsmeier M, Obeidat F, Seeliger H, Jauch KW, Bruns CJ. The challenge of pancreatic anastomosis. Langenbeck's Archives of Surgery 2008;393:459–471.
Wente MN, Veit JA, Bassi C, Dervenis C, Fingerhut A, Gouma DJ, Izbicki JR, Neoptolemos JP, Padbury RT, Sarr MG, Yeo CJ, Buchler MW. Postpancreatectomy hemorrhage (PPH): an International Study Group of Pancreatic Surgery (ISGPS) definition. Surgery 2007;142:20–5.
Buchler MW, Friess H, Wagner M, Kulli C, Wagener V, Z'Graggen K. Pancreatic fistula after pancreatic head resection. Br J Surg 2000;87:883–9.
Wei HK, Wang SE, Shyr YM, Tseng HS, Tsai WC, Chen TH, Su CH, Wu CW, Lui WY. Risk factors for post-pancreaticoduodenectomy bleeding and finding an innovative approach to treatment. Dig Surg 2009;26:297–305.
Choi SH, Moon HJ, Heo JS, Joh JW, Kim YI. Delayed hemorrhage after pancreaticoduodenectomy. J Am Coll Surg 2004;199:186–91.
Liu C, Qiu YH, Luo XJ, Yi B, Jiang XQ, Tan WF, Yu Y, Wu MC. Treatment of massive pancreaticojejunal anastomotic hemorrhage after pancreatoduodenectomy. World J Gastroenterol 2009;15:1625–9.
Treckmann J, Paul A, Sotiropoulos GC, Lang H, Ozcelik A, Saner F, Broelsch CE. Sentinel bleeding after pancreaticoduodenectomy: a disregarded sign. J Gastrointest Surg 2008;12:313–8.
Yekebas EF, Wolfram L, Cataldegirmen G, Habermann CR, Bogoevski D, Koenig AM, Kaifi J, Schurr PG, Bubenheim M, Nolte-Ernsting C, Adam G, Izbicki JR. Postpancreatectomy hemorrhage: diagnosis and treatment: an analysis in 1669 consecutive pancreatic resections. Ann Surg 2007;246:269–80.
Yoon YS, Kim SW, Her KH, Park YC, Ahn YJ, Jang JY, Park SJ, Suh KS, Han JK, Lee KU, Park YH. Management of postoperative hemorrhage after pancreatoduodenectomy. Hepatogastroenterology 2003;50:2208–12.
Balachandran P, Sikora SS, Raghavendra Rao RV, Kumar A, Saxena R, Kapoor VK. Haemorrhagic complications of pancreaticoduodenectomy. ANZ J Surg 2004;74:945–50.
Blanc T, Cortes A, Goere D, Sibert A, Pessaux P, Belghiti J, Sauvanet A. Hemorrhage after pancreaticoduodenectomy: when is surgery still indicated? Am J Surg 2007;194:3–9.
Boggi U, Del Chiaro M, Croce C, Amorese G, Signori S, Vistoli F, Di Candio G, Campatelli A, Morelli L, D'Imporzano S, Sgambelluri FA, Mosca I, Mosca F. Vascular complications of pancreatectomy. JOP 2007;8:102–13.
Koukoutsis I, Bellagamba R, Morris-Stiff G, Wickremesekera S, Coldham C, Wigmore SJ, Mayer AD, Mirza DF, Buckels JA, Bramhall SR. Haemorrhage following pancreaticoduodenectomy: risk factors and the importance of sentinel bleed. Dig Surg 2006;23:224–8.
Makowiec F, Riediger H, Euringer W, Uhl M, Hopt UT, Adam U. Management of delayed visceral arterial bleeding after pancreatic head resection. J Gastrointest Surg 2005;9:1293–9.
Miura F, Asano T, Amano H, Yoshida M, Toyota N, Wada K, Kato K, Yamazaki E, Kadowaki S, Shibuya M, Maeno S, Furui S, Takeshita K, Kotake Y, Takada T. Management of postoperative arterial hemorrhage after pancreato-biliary surgery according to the site of bleeding: re-laparotomy or interventional radiology. J Hepatobiliary Pancreat Surg 2009;16:56–63.
Sato N, Yamaguchi K, Shimizu S, Morisaki T, Yokohata K, Chijiiwa K, Tanaka M. Coil embolization of bleeding visceral pseudoaneurysms following pancreatectomy: the importance of early angiography. Arch Surg 1998;133:1099–102.
Reber PU, Baer HU, Patel AG, Wildi S, Triller J, Buchler MW. Superselective microcoil embolization: treatment of choice in high-risk patients with extrahepatic pseudoaneurysms of the hepatic arteries. J Am Coll Surg 1998;186:325–30.
Sugimoto H, Kaneko T, Ishiguchi T, Takai K, Ohta T, Yagi Y, Inoue S, Takeda S, Nakao A. Delayed rupture of a pseudoaneurysm following pancreatoduodenectomy: Report of a case. Surgery Today 2001;31:932–935.
Otah E, Cushin BJ, Rozenblit GN, Neff R, Otah KE, Cooperman AM. Visceral artery pseudoaneurysms following pancreatoduodenectomy. Arch Surg 2002;137:55–9.
Santoro R, Carlini M, Carboni F, Nicolas C, Santoro E. Delayed massive arterial hemorrhage after pancreaticoduodenectomy for cancer. Management of a life-threatening complication. Hepatogastroenterology 2003;50:2199–204.
Brodsky JT, Turnbull AD. Arterial hemorrhage after pancreatoduodenectomy. The ‘sentinel bleed’. Arch Surg 1991;126:1037–40.
Tien YW, Wu YM, Liu KL, Ho CM, Lee PH. Angiography is indicated for every sentinel bleed after pancreaticoduodenectomy. Ann Surg Oncol 2008;15:185561.
de Castro SM, Kuhlmann KF, Busch OR, van Delden OM, Lameris JS, van Gulik TM, Obertop H, Gouma DJ. Delayed massive hemorrhage after pancreatic and biliary surgery: embolization or surgery? Ann Surg 2005;241:85–91.
de Castro SM, Busch OR, Gouma DJ. Management of bleeding and leakage after pancreatic surgery. Best Pract Res Clin Gastroenterol 2004;18:847–64.
Gervais DA, Fernandez-del Castillo C, O'Neill MJ, Hahn PF, Mueller PR. Complications after pancreatoduodenectomy: imaging and imaging-guided interventional procedures. Radiographics 2001;21:673–90.
vanSonnenberg E, Wittich GR, Goodacre BW, Casola G, D'Agostino HB. Percutaneous abscess drainage: update. World J Surg 2001;25:362–9; discussion 370–2.
Turrini O, Moutardier V, Guiramand J, Lelong B, Bories E, Sannini A, Magnin V, Viret F, Blache JL, Giovannini M, Delpero JR. Hemorrhage after duodenopancreatectomy: impact of neoadjuvant radiochemotherapy and experience with sentinel bleeding. World J Surg 2005;29:212–6.
Kurosaki I, Hatakeyama K. Omental wrapping of skeletonized major vessels after pancreaticoduodenectomy. Int Surg 2004;89:90-4.
Balladur P, Christophe M, Tiret E, Parc R. Bleeding of the pancreatic stump following pancreatoduodenectomy for cancer. Hepatogastroenterology 1996;43:268–70.
Cullen JJ, Sarr MG, Ilstrup DM. Pancreatic anastomotic leak after pancreaticoduodenectomy: incidence, significance, and management. Am J Surg 1994;168:295–8.
Reber PU, Baer HU, Patel AG, Triller J, Buchler MW. Life-threatening upper gastrointestinal tract bleeding caused by ruptured extrahepatic pseudoaneurysm after pancreatoduodenectomy. Surgery 1998;124:114–5.
Noun R, Zeidan S, Tohme-Noun C, Smayra T, Sayegh R. Biliary ischemia following embolization of a pseudoaneurysm after pancreaticoduodenectomy. Journal of the Pancreas 2006;7:427–431.
Burger T, Halloul Z, Meyer F, Grote R, Lippert H. Emergency stent-graft repair of a ruptured hepatic artery secondary to local postoperative peritonitis. J Endovasc Ther 2000;7:324–7.
Heiss P, Bachthaler M, Hamer OW, Piso P, Herold T, Schlitt HJ, Feuerbach S, Zorger N. Delayed visceral arterial hemorrhage following Whipple's procedure: minimally invasive treatment with covered stents. Ann Surg Oncol 2008;15:824–32.
Stoupis C, Ludwig K, Inderbitzin D, Do DD, Triller J. Stent grafting of acute hepatic artery bleeding following pancreatic head resection. Eur Radiol 2007;17:401–8.
McGraw JK, Patzik SB, Gale SS, Dodd JT, Boorstein JM. Autogenous vein-covered stent for the endovascular management of a superior mesenteric artery pseudoaneurysm. J Vasc Interv Radiol 1998;9:779–82.
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Roulin, D., Cerantola, Y., Demartines, N. et al. Systematic Review of Delayed Postoperative Hemorrhage after Pancreatic Resection. J Gastrointest Surg 15, 1055–1062 (2011). https://doi.org/10.1007/s11605-011-1427-8
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DOI: https://doi.org/10.1007/s11605-011-1427-8