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Bleeding pancreatic pseudoaneurysms: management by angioembolization combined with therapeutic endoscopy

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Abstract

Background

Bleeding pancreatic pseudocysts (PPCs) are a rare but lethal complication of pancreatitis. Transcatheter arterial embolization (TAE) is the first-line treatment of acute hemorrhage, but consensus on the definitive management of bleeding PPCs is lacking. The aim of this study was to evaluate the safety and efficacy of the combination of TAE and therapeutic endoscopy in the treatment of bleeding PPCs.

Methods

Patients with acute or chronic pancreatitis treated for bleeding PPCs in Helsinki University Hospital during 2004–2014 comprised the study group. Inpatients with acute necrotizing pancreatitis were excluded. Patients underwent TAE as the primary treatment to control the bleeding. Therapeutic endoscopy performed on an outpatient visit after TAE allowed the definitive treatment of PPCs.

Results

A total of 58 patients underwent TAE. Re-bleeding rate (<30 days) was 15.5 %, necessitating re-embolization on seven and surgical intervention on two patients. Overall, TAE success rate was 96.6 %. Mortality rate (<30 days) was 3.4 %. Of the 58, 47 patients were followed up for their PPCs in our unit. PPCs resolved spontaneously in 13 (27.1 %). The remaining 34 had an endoscopic treatment attempt with endoscopic draining performed on 32 and unsuccessful cannulation on two (5.9 %). Of the 32 patients with initially successful endoscopy, 7 (21.9 %) needed an additional drainage procedure (six non-surgical and one surgical). Overall success rate of non-surgical management was 91.5 %. Post-endoscopy mortality rate (<30 days) was 2.9 %. Our follow-up continued for 15 (1–75) months. By the time of data retrieval, 35 of 58 patients had died with alcohol liver disease being the most common cause of death. Five-year survival estimate was 63 %.

Conclusions

Bleeding pancreatic pseudoaneurysms require non-surgical management. We need more data on the optimal timing of therapeutic endoscopy and on the role of empirical embolizations.

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References

  1. Andrén-Sandberg Å, Dervenis C (2004) Pancreatic pseudocysts in the 21st century. Part I: classification, pathophysiology, anatomic considerations and treatment. J Pancreas 5:8–24

    Google Scholar 

  2. Balthazar EJ, Fisher LA (2001) Hemorrhagic complications of pancreatitis: radiologic evaluation with emphasis on CT imaging. Pancreatology 1:306–313. doi:10.1159/000055829

    Article  CAS  PubMed  Google Scholar 

  3. Bergert H, Hinterseher I, Kersting S, Leonhardt J, Bloomenthal A, Saeger HD (2005) Management and outcome of hemorrhage due to arterial pseudoaneurysms in pancreatitis. Surgery 137:323–328. doi:10.1016/j.surg.2004.10.009

    Article  PubMed  Google Scholar 

  4. Udd M, Leppäniemi AK, Bidel S, Keto P, Roth W-D, Haapiainen RK (2007) Treatment of bleeding pseudoaneurysms in patients with chronic pancreatitis. World J Surg 31:504–510. doi:10.1007/s00268-006-0209-z

    Article  PubMed  Google Scholar 

  5. Chiang K-C, Chen T-H, Hsu J-T (2014) Management of chronic pancreatitis complicated with a bleeding pseudoaneurysm. WJG 20:16132–16137. doi:10.3748/wjg.v20.i43.16132

    Article  PubMed  PubMed Central  Google Scholar 

  6. Kim J, Shin JH, Yoon H-K, Ko G-Y, Gwon DI, Kim E-Y, Sung K-B (2015) Endovascular intervention for management of pancreatitis-related bleeding: a retrospective analysis of thirty-seven patients at a single institution. Diagn Interv Radiol 21:140–147. doi:10.5152/dir.2014.14085

    Article  PubMed  PubMed Central  Google Scholar 

  7. Nicholson AA, Patel J, McPherson S, Shaw DR, Kessel D (2006) Endovascular treatment of visceral aneurysms associated with pancreatitis and a suggested classification with therapeutic implications. J Vasc Interv Radiol 17:1279–1285. doi:10.1097/01.RVI.0000231948.08617.04

    Article  PubMed  Google Scholar 

  8. Balachandra S, Siriwardena AK (2005) Systematic appraisal of the management of the major vascular complications of pancreatitis. Am J Surg 190:489–495. doi:10.1016/j.amjsurg.2005.03.009

    Article  PubMed  Google Scholar 

  9. Kirby JM, Vora P, Midia M, Rawlinson J (2007) Vascular complications of pancreatitis: imaging and intervention. Cardiovasc Interv Radiol 31:957–970. doi:10.1007/s00270-007-9138-y

    Article  Google Scholar 

  10. Dumonceau J-M (2013) Endoscopic management of complications of chronic pancreatitis. WJG 19:7308–7309. doi:10.3748/wjg.v19.i42.7308

    Article  PubMed  PubMed Central  Google Scholar 

  11. Tandan M (2013) Endotherapy in chronic pancreatitis. WJG 19:6156–6164. doi:10.3748/wjg.v19.i37.6156

    Article  PubMed  PubMed Central  Google Scholar 

  12. Dumonceau JM, Delhaye M, Tringali A, Dominguez-Munoz J, Poley JW, Arvanitaki M, Costamagna G, Costea F, Devière J, Eisendrath P, Lakhtakia S, Reddy N, Fockens P, Ponchon T, Bruno M (2012) Endoscopic treatment of chronic pancreatitis: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. Endoscopy 44:784–800. doi:10.1055/s-0032-1309840

    Article  PubMed  Google Scholar 

  13. Varadarajulu S, Bang JY, Sutton BS, Trevino JM, Christein JD, Wilcox CM (2013) Equal efficacy of endoscopic and surgical cystogastrostomy for pancreatic pseudocyst drainage in a randomized trial. Gastroenterology 145(583–590):e1. doi:10.1053/j.gastro.2013.05.046

    Google Scholar 

  14. Johnson MD, Walsh M, Henderson JM, Brown N, Ponsky J, Dumont J, Zuccaro G, Vargo J (2009) Surgical versus nonsurgical management of pancreatic pseudocysts. J Clin Gastroenterol 43:586–590

    Article  PubMed  Google Scholar 

  15. Bhasin DK, Rana SS, Sharma V, Rao C, Gupta V, Gupta R, Kang M, Singh K (2013) Non-surgical management of pancreatic pseudocysts associated with arterial pseudoaneurysm. Pancreatology 13:250–253. doi:10.1016/j.pan.2013.02.011

    Article  PubMed  Google Scholar 

  16. Elton E, Howell D, Amberson S, Dykes T (1997) Combined angiographic and endoscopic management of bleeding pancreatic pseudoaneurysms. Gastrointest Endosc 46:544–549

    Article  CAS  PubMed  Google Scholar 

  17. Sayilir A, Onal IK, Beyazit Y, Surmelioglu A, Salper Okten R, Odemis B, Parlak E, Sasmaz N (2011) A rare cause of upper gastrointestinal bleeding: hemosuccus pancreaticus: angiographic and endoscopic combined treatment. Surg Laparosc Endosc Percutaneous Techn 21:e286–e287. doi:10.1097/SLE.0b013e31822f50b6

    Article  Google Scholar 

  18. Cotton PB, Lehman G, Vennes J, Geenen JE, Russel RC, Meyers WC, Liguory C, Nickl N (1991) Endoscopic sphincterotomy complications and their management: an attempt at consensus. Gastrointest Endosc 37:383–393

    Article  CAS  PubMed  Google Scholar 

  19. Barge JU, Lopera JE (2012) Vascular complications of pancreatitis: role of interventional therapy. Korean J Radiol 13:S45–S55. doi:10.3348/kjr.2012.13.S1.S45

    Article  PubMed  PubMed Central  Google Scholar 

  20. Park D, Lee S, Moon SH, Choi S, Jung S, Seo D, Lee S, Kim MH (2009) Endoscopic ultrasound-guided versus conventional transmural drainage for pancreatic pseudocysts: a prospective randomized trial. Endoscopy 41:842–848. doi:10.1055/s-0029-1215133

    Article  CAS  PubMed  Google Scholar 

  21. Weckman L, Kylänpää ML, Puolakkainen P, Halttunen J (2006) Endoscopic treatment of pancreatic pseudocysts. Surg Endosc 20:603–607. doi:10.1007/s00464-005-0201-y

    Article  CAS  PubMed  Google Scholar 

  22. Arvanitakis M, Delhaye M, Bali MA, Matos C, De Maertelaer V, Le Moine O, Devière J (2007) Pancreatic-fluid collections: a randomized controlled trial regarding stent removal after endoscopic transmural drainage. Gastrointest Endosc 65:609–619. doi:10.1016/j.gie.2006.06.083

    Article  Google Scholar 

  23. Cahen D, Rauws E, Fockens P, Weverling G, Huibregtse K, Bruno M (2005) Endoscopic drainage of pancreatic pseudocysts: long-term outcome and procedural factors associated with safe and successful treatment. Endoscopy 37:977–983. doi:10.1055/s-2005-870336

    Article  CAS  PubMed  Google Scholar 

  24. Yang D, Amin S, Gonzalez S, Mullady D, Hasak S, Gaddam S, Edmundowicz S, Gromski M, DeWitt J, Zein MD, El M, Khashab M, Wang A, Gaspar J, Uppal D, Nagula S, Kapadia S, Buscaglia J, Bucobo JC, Schlachterman A, Wagh M, Draganov P, Kyu Jung M, Stevens T, Vargo J, Khara H, Huseini M, Diehl D, Keswani R, Law R, Komanduri S, Yachimski P, DaVee T, Prabhu A, Lapp R, Kwon R, Watson R, Goodman A, Chhabra N, Wang W, Benias P, Carr-Locke D, DiMaio C (2016) Transpapillary drainage has no added benefit on treatment outcomes in patients undergoing EUS-guided transmural drainage of pancreatic pseudocysts: a large multicenter study. Gastrointest Endosc 83:720–729. doi:10.1016/j.gie.2015.10.040

    Article  PubMed  Google Scholar 

  25. Andersson E, Ansari D, Andersson R (2010) Major haemorrhagic complications of acute pancreatitis. Br J Surg 97:1379–1384. doi:10.1002/bjs.7113

    Article  CAS  PubMed  Google Scholar 

  26. Lankisch PG, Weber-Dany B, Maisonneuve P, Lowenfels AB (2012) Pancreatic pseudocysts: prognostic factors for their development and their spontaneous resolution in the setting of acute pancreatitis. Pancreatology 12:85–90. doi:10.1016/j.pan.2012.02.007

    Article  PubMed  Google Scholar 

  27. Mehta R, Suvarna D, Sadasivan S, John A, Raj V, Nair P, Balakrishnan V (2004) Natural course of asymptomatic pancreatic pseudocyst: a prospective study. Indian J Gastroenterol 23:140–142

    PubMed  Google Scholar 

  28. Andrén-Sandberg Å, Dervenis C (2004) Pancreatic pseudocysts in the 21st century. Part II: natural history. J Pancreas 5:64–70

    Google Scholar 

  29. Bradley EL, Gonzalez AC, Clements JR Jr (1976) Acute pancreatic pseudocysts: incidence and implications. Ann Surg 184:734–737

    Article  CAS  PubMed  PubMed Central  Google Scholar 

Download references

Acknowledgments

One-month researcher’s salary paid for Taina Nykänen by the Helsinki University Hospital Research Fund to allow full-time research.

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Authors and Affiliations

  1. Gastroenterological surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland

    Taina Nykänen, Marianne Udd, Ari Leppäniemi & Leena Kylänpää

  2. Interventional radiology, University of Helsinki and Helsinki Univeristy Hospital, Helsinki, Finland

    Erno K. Peltola

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  1. Taina Nykänen
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  2. Marianne Udd
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Correspondence to Taina Nykänen.

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Marianne Udd, Erno Peltola, Ari Leppäniemi and Leena Kylänpää have no conflicts of interest or financial ties to disclose.

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Nykänen, T., Udd, M., Peltola, E.K. et al. Bleeding pancreatic pseudoaneurysms: management by angioembolization combined with therapeutic endoscopy. Surg Endosc 31, 692–703 (2017). https://doi.org/10.1007/s00464-016-5023-6

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