Risk for hemorrhage after pancreatoduodenectomy with venous resection
No consensus exists on the optimal anticoagulation therapy after pancreatoduodenectomy with venous resection (PDVR). The aim of the study was to analyze perioperative outcomes of patients receiving low- vs high-dose anticoagulation therapy and to identify risk factors for postpancreatectomy hemorrhage in patients undergoing PDVR.
Retrospective study of patients undergoing PDVR at a tertiary referral center between January 2006 and April 2017. Patients were investigated according to the dose of postoperative anticoagulation given (low- or high-dose low-molecular-weight heparin). Uni- and multivariate analysis were performed to assess risk factors for postpancreatectomy hemorrhage.
A total of 141 patients underwent PDVR. Low-dose anticoagulation was given to 45 (31.9%) patients. Operative time (428 min vs 398 min, p = 0.025) and the use of interposition grafts (27% vs 11%, P = 0.033) were significantly higher in the high-dose group. There was no difference in the rate of early portal vein thrombosis (4.4% vs 4.2%, p = 0.939) or postpancreatectomy hemorrhage (13.3% vs 16.7%, p = 0.611) between the low- and high-dose groups. On multivariate analysis, serum bilirubin ≥ 200 μmol/L and clinically relevant postoperative fistula were the only factors associated with postpancreatectomy hemorrhage (OR 10.28, 95% CI 3.51–30.07, P < 0.001, and OR 6.39, 95% CI 1.59–25.74, P = 0.009).
Preoperative hyperbilirubinemia and clinically relevant postoperative fistula are risk factors for postpancreatectomy hemorrhage after PDVR. Rates of postpancreatectomy hemorrhage did not differ between patients receiving high- vs low-dose low-molecular-weight heparin.
KeywordsPancreatoduodenectomy with venous resection Anticoagulation policy
Compliance with ethical standards
Conflict of interest
The authors declare that they have no conflict of interest.
All procedures performed in studies involving human participants were in accordance with ethical standards of the institutional and national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
Informed consent was not obtained by all participants. The study was permitted by the hospital review board in accordance with the regional ethical committee.
- 1.Worni M, Castleberry AW, Clary BM, Gloor B, Carvalho E, Jacobs DO, Pietrobon R, Scarborough JE, White RR (2013) Concomitant vascular reconstruction during pancreatectomy for malignant disease: a propensity score-adjusted, population-based trend analysis involving 10,206 patients. JAMA Surg 148:331–338CrossRefGoogle Scholar
- 4.Malleo G, Maggino L, Marchegiani G, Feriani G, Esposito A, Landoni L, Casetti L, Paiella S, Baggio E, Lipari G, Capelli P, Scarpa A, Bassi C, Salvia R (2017) Pancreatectomy with venous resection for pT3 head adenocarcinoma: Perioperative outcomes, recurrence pattern and prognostic implications of histologically confirmed vascular infiltration. Pancreatology 17:847–857CrossRefGoogle Scholar
- 5.Ravikumar R, Sabin C, Abu Hilal M, al-Hilli A, Aroori S, Bond-Smith G, Bramhall S, Coldham C, Hammond J, Hutchins R, Imber C, Preziosi G, Saleh A, Silva M, Simpson J, Spoletini G, Stell D, Terrace J, White S, Wigmore S, Fusai G (2017) Impact of portal vein infiltration and type of venous reconstruction in surgery for borderline resectable pancreatic cancer. Br J Surg 104:1539–1548CrossRefGoogle Scholar
- 10.National Comprehensive Cancer Network. NCCN clinical practice guidelines in oncology. Pancreatic adenocarcinoma version 2. 2017. Available at: http://www.nccn.org/professionals/physicians_gls/pdf/pancreatic.pdf., 2017
- 14.Slankamenac K, Nederlof N, Pessaux P, de Jonge J, Wijnhoven BPL, Breitenstein S, Oberkofler CE, Graf R, Puhan MA, Clavien PA (2014) The comprehensive complication index: a novel and more sensitive endpoint for assessing outcome and reducing sample size in randomized controlled trials. Ann Surg 260:757–762 discussion 762-753 CrossRefGoogle Scholar
- 16.Bassi C, Marchegiani G, Dervenis C, Sarr M, Abu Hilal M, Adham M, Allen P, Andersson R, Asbun HJ, Besselink MG, Conlon K, del Chiaro M, Falconi M, Fernandez-Cruz L, Fernandez-del Castillo C, Fingerhut A, Friess H, Gouma DJ, Hackert T, Izbicki J, Lillemoe KD, Neoptolemos JP, Olah A, Schulick R, Shrikhande SV, Takada T, Takaori K, Traverso W, Vollmer CR, Wolfgang CL, Yeo CJ, Salvia R, Buchler M, International Study Group on Pancreatic Surgery (ISGPS) (2017) The 2016 update of the International Study Group (ISGPS) definition and grading of postoperative pancreatic fistula: 11 years after. Surgery 161:584–591CrossRefGoogle Scholar
- 25.Bergqvist D, Burmark US, Flordal PA, Frisell J, Hallböökr T, Hedberg M, Horn A, Kelty E, Kvitting P, Lindhagen A, Ljungström KG, Mätzsch T, Risberg B, Syk I, Törngren S, Wellander E, Örtenwall P (1995) Low molecular weight heparin started before surgery as prophylaxis against deep vein thrombosis: 2500 versus 5000 XaI units in 2070 patients. Br J Surg 82:496–501CrossRefGoogle Scholar
- 30.Diamond T, Rowlands BJ (1991) Endotoxaemia in obstructive jaundice. HPB (Oxford) 4:81–94Google Scholar
- 32.Scheufele F, Schorn S, Demir IE, Sargut M, Tieftrunk E, Calavrezos L, Jäger C, Friess H, Ceyhan GO (2017) Preoperative biliary stenting versus operation first in jaundiced patients due to malignant lesions in the pancreatic head: a meta-analysis of current literature. Surgery 161:939–950CrossRefGoogle Scholar
- 35.Sanjay P, Fawzi A, Fulke JL, Kulli C, Tait IS, Zealley IA, Polignano FM (2010) Late post pancreatectomy haemorrhage. Risk factors and modern management. JOP 11:220–225Google Scholar