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

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Journal of Gastrointestinal Surgery Aims and scope

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 re-laparotomy 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.

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References

  1. Shankar S, Russell RCG. Hemorrhage in pancreatic disease. Br J Surg 1989;76:863–866.

    Article  PubMed  CAS  Google Scholar 

  2. Brodsky JT, Turnbull AD. Arterial hemorrhage after pancreatoduodenectomy. The sentinel bleed. Arch Surg 1991;126:1037–1040.

    PubMed  CAS  Google Scholar 

  3. Rumstadt B, Schwab M, Korth P, Samman M, Trede M. Hemorrhage after pancreatoduodenectomy. Ann Surg 1998;227:236–241.

    Article  PubMed  CAS  Google Scholar 

  4. van Berge Henegouwen MI, Allema JH, van Gulik TM, Verbeek PCM, Obertop H, Gouma DJ. Delayed massive haemorrhage after pancreatic and biliary surgery. Br J Surg 1995;82:1527–1531.

    Article  PubMed  Google Scholar 

  5. Bassi C, Falconi M, Salvia R, Mascetta G, Molinari E, Pederzoli P. Management of complications after pancreaticoduodenectomy in a high volume center: Results on 150 consecutive patients. Dig Surg 2001;18:453–458.

    Article  PubMed  CAS  Google Scholar 

  6. 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;50:2199–2204.

    PubMed  Google Scholar 

  7. Gmbiez LP, Ernst OJ, Merlier OA, Porte HL, Chambon JPM, Quandalle PA. Arterial embolization for bleeding pseudocysts: complicating chronic pancreatitis. Arch Surg 1997;132:1016–1021.

    Google Scholar 

  8. Gorich J, Rilinger N, Huppert P, et al. Non-operative management of arterial liver hemorrhages. Eur Radiol 1999;9:85–88.

    Article  PubMed  CAS  Google Scholar 

  9. Sato N, Yamaguchi K, Shimizu S, et al. Coil embolization of bleeding visceral pseudoaneurysms following pancreatectomy. The importance of early angiography. Arch Surg 1998;133:1099–1102.

    Article  PubMed  CAS  Google Scholar 

  10. Reber PU, Baer HU, Patel AG, Wildi S, Triller J, Büchler MW. Superselective microcoil embolization: Treatment of choice in high-risk patients with extrahepatic pseudoaneurysms of the hepatic arteries. J Am Coll Surg 1998;186:325–330.

    Article  PubMed  CAS  Google Scholar 

  11. Yoon YS, Kim SW, Her KH, et al. Management of postoperative hemorrhage after pancreatoduodenectomy. Hepatogastroenterology 2003;50:2208–2212.

    PubMed  Google Scholar 

  12. Okuno A, Miyazaki M, Ito H, et al. Nonsurgical management of ruptured pseudoaneurysm in patients with hepatobiliary pancreatic diseases. Am J Gastroenterol 2001;96:1067–1071.

    Article  PubMed  CAS  Google Scholar 

  13. Otah E, Cushin BJ, Rozenblit GN, Neff R, Otah KE, Cooperman AM. Visceral artery pseudoaneurysms following pancreatoduodenectomy. Arch Surg 2002;137:55–59.

    Article  PubMed  Google Scholar 

  14. Sugimoto H, Kaneko T, Ishiguchi T, et al. Delayed rupture of a pseudoaneurysm following pancreatoduodenectomy: report of a case. Surg Today 2001;31:932–935.

    Article  PubMed  CAS  Google Scholar 

  15. Aranha GV, O’Neil S, Borge MA. Successful nonoperative management of bleeding hepatic artery pseudoaneurysm following pancreaticoduodenectomy. Dig Surg 1999;16:528–530.

    Article  PubMed  CAS  Google Scholar 

  16. Shibata T, Sagoh T, Ametani F, Maetani Y, Itoh K, Konishi J. Transcatheter microcoil embolotherapy for ruptured pseudoaneurysm following pancreatic and biliary surgery. Cardiovasc Interv Radiol 2002;25:180–185.

    Article  Google Scholar 

  17. Choi SH, Moon HJ, Heo JS, Joh JW, Kim YI. Delayed hemorrhage after pancreaticoduodenectomy. J Am Coll Surg 2004;199:186–191.

    Article  PubMed  Google Scholar 

  18. de Weerth A, Buggisch P, Nicolas V, Maas R. Pancreaticoduodenal artery aneurysm—a life threatening cause of gastrointestinal hemorrhage: Case report and review of the literature. Hepatogastroenterology 1998;45:1651–1654.

    PubMed  Google Scholar 

  19. Paci E, Antico E, Candelari R, Alborino S, Marmorale C, Landi E. Pseudoaneurysm of the common hepatic artery: Treatment with a stent-graft. Cardiovasc Interv Radiol 2000;23:472–484.

    Article  CAS  Google Scholar 

  20. Tan M, di Carlo AD, Stein LA, Cantarovich M, Tchervenkov JI, Metrakos P. Pseudoaneurysm of the superior mesenteric artery after pancreas transplantation treated by endovascular stenting. Transplantation 2001;72:336–338.

    Article  PubMed  CAS  Google Scholar 

  21. Mansueto G, D’Onofrio M, Lacono C, Rozzanigo U, Serio G, Procacci C. Gastroduodenal artery stump haemorrhage following pylorus-sparing Whipple procedure: Treatment with covered stents. Dig Surg 2002;19:237–240.

    Article  PubMed  Google Scholar 

  22. Rami P, Williams D, Forauer A, Cwikiel W. Stent-graft treatment of patients with acute bleeding from hepatic artery branches. Cardiovasc Interv Radiol 2005;28:153–158.

    Article  Google Scholar 

  23. Yamaguchi K, Tanaka M, Chijiiwa K, Nagakawa T, Imamura M, Takada T. Early and late complications of pylorus-preserving pancreatoduodenectomy in Japan 1998. J Hepatobil Pancreat Surg 1999;6:303–311.

    Article  CAS  Google Scholar 

  24. Balachandran P, Sikora SS, Raghavendra Rao RV, Kumar A, Saxena R, Kapoor VK. Haemorrhagic complications of pancreaticoduodenectomy. ANZ J Surg 2004;74:945–950.

    Article  PubMed  Google Scholar 

  25. Takahashi T, Shimada K, Kobayashi N, Kakita A. Migration of steel-wire coils into the stomach after transcatheter arterial embolization for a bleeding splenic artery pseudoaneurysm: Report of a case. Surg Today 2001;31:458–462.

    Article  PubMed  CAS  Google Scholar 

  26. Teramoto K, Kawamura T, Takamatsu S, Noguchi N, Arii S. A case of hepatic artery embolization and partial arterialization of the portal vein for intraperitoneal hemorrhage after a pancreaticoduodenectomy. Hepatogastroenterology 2003;50:1217–1219.

    PubMed  Google Scholar 

  27. de Perrot M, Berney T, Buhler L, Delgadillo X, Mentha G, Morel P. Management of bleeding pseudoaneurysms in patients with pancreatitis. Br J Surg 1999;86:29–32.

    Article  PubMed  Google Scholar 

  28. Balsarkar DJ, Joshi MA. Rupture of splenic artery pseudoaneurysm presenting with massive upper gastrointestinal bleed. Am J Surg 2002;183:197–198.

    Article  PubMed  Google Scholar 

  29. Farley DR, Schwall G, Trede M. Completion pancreatectomy for surgical complications after pancreaticoduodenectomy. Br J Surg 1996;83:176–179.

    Article  PubMed  CAS  Google Scholar 

  30. Smith CD, Sarr MG, vanHeerden JA. Completion pancreatectomy following pancreaticoduodenectomy: Clinical experience. World J Surg 1992;16:521–524.

    Article  PubMed  CAS  Google Scholar 

  31. Sarr MG, Warshaw AL. Causes and management of pseudoaneurysms. Surg 1998;124:116–117.

    CAS  Google Scholar 

  32. Wu CC, Hwang CR, Yeh DC, Hwang YC, Liu TJ, P’eng FK. Treatment for dehiscence of pancreaticojejunostomy after pancreaticoduodenectomy: Is resection of the residual pancreas necessary? Hepatogastroenterology 1996;43:271–274.

    PubMed  CAS  Google Scholar 

  33. Buchler MW, Friess H, Wagner M, Kulli C, Wagener V, Z’graggen K. Pancreatic fistula after pancreatic head resection. Br J Surg 2000;87:883–889.

    Article  PubMed  CAS  Google Scholar 

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Authors and Affiliations

  1. Department of Gastroenterological Surgery, Yokohama City University School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama, 236-0004, Japan

    Yoshiro Fujii, Hiroshi Shimada, Itaru Endo, Ken-ichi Yoshida, Ken-ichi Matsuo, Kazuhisa Takeda, Michio Ueda, Daisuke Morioka, Kuniya Tanaka & Shinji Togo

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  1. Yoshiro Fujii
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  2. Hiroshi Shimada
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  3. Itaru Endo
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  4. Ken-ichi Yoshida
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  6. Kazuhisa Takeda
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Correspondence to Yoshiro Fujii.

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Fujii, Y., Shimada, H., Endo, I. et al. Management of Massive Arterial Hemorrhage After Pancreatobiliary Surgery: Does Embolotherapy Contribute to Successful Outcome?. J Gastrointest Surg 11, 432–438 (2007). https://doi.org/10.1007/s11605-006-0076-9

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  • DOI: https://doi.org/10.1007/s11605-006-0076-9

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