Multiple episodes of postpancreatectomy hemorrhage resolved by endoscopy and ultrasound-guided percutaneous thrombin injection into a common hepatic artery aneurysm: a case report

Postpancreatectomy hemorrhage (PPH) is one of the most common complications after pancreatoduodenectomy (PD). It mainly includes gastrointestinal hemorrhage and abdominal hemorrhage. With the development of digestive endoscopy and ultrasonic/radiological interventional technology, hemostasis can be effectively performed by minimally invasive methods in many patients with PPH. This report describes the successful treatment of multiple episodes of postoperative hemorrhage after PD. The patient developed anastomotic hemorrhage after PD and was successfully treated by endoscopic hemostasis. However, he also developed intra-abdominal hemorrhage after PD caused by a pseudoaneurysm that had formed next to the common hepatic artery. We effectively performed hemostasis by injecting lyophilized thrombin powder into the pseudoaneurysm with ultrasound guidance, which is a rarely used method. This case indicates that digestive endoscopy provides great advantages in the treatment of gastrointestinal hemorrhage after PD. For patients who develop PPH with a pseudoaneurysm, interventional ultrasonography is an option if transcatheter arterial embolization or covered stenting fails.

Postpancreatectomy hemorrhage: classification, epidemiology, risk factors

The paper analyzes modern literature data regarding post-resection hemorrhagic complications in surgical pancreatology. The modern classification system, epidemiological data and risk factors for postoperative bleeding are analyzed in detail. Critical analysis of the use of postpancreatectomy hemorrhage classification was carried out.

Late postpancreatectomy hemorrhage from the gastroduodenal artery stump into an insufficient hepaticojejunostomy: a case report

Background Mortality after elective pancreatic surgery in modern high-volume centers is very low. Morbidity remains high, affecting 20–40% of patients. Late postpancreatectomy hemorrhage is a rare but potentially lethal complication. The exceptionality in our case lies in the underlying mechanism of its clinical presentation. It is a demonstration of the difficulties associated with finding the source of bleeding in late postpancreatectomy hemorrhage. Case presentation An 82-year-old White female was diagnosed with a periampullary malignancy and underwent pancreatoduodenectomy. Postoperatively, the patient suffered from an anastomotic leak in the hepaticojejunostomy, which was treated with percutaneous pigtail drains in the abdomen and in the biliary tract. On the fourth postoperative week she presented blood in both drains and in her stool. Given our knowledge about the biliary anastomotic leak, this presentation led us to suspect an intraluminal source (biliary tract or gastrojejunostomy) with blood leaking through the insufficient hepaticojejunostomy into the abdominal cavity. Upper tract endoscopy and computed tomography angiography were, however, unremarkable. Further investigation with conventional angiography identified the bleeding source at the gastroduodenal artery stump, which was successfully coiled. Hence, the gastroduodenal artery stump was bleeding into the insufficient hepaticojejunostomy, filling up the biliary tree and the small intestine. After coiling of the artery, the remainder of the postoperative care was uneventful. Conclusion Postpancreatectomy hemorrhage presents a major clinical challenge after pancreatoduodenectomy, with significant morbidity and high risk for mortality. The treating physician must be alert and active in the investigation and treatment of the bleeding source to ensure a successful outcome.

Wrapping the stump of the gastroduodenal artery using the ligamentum teres hepatis during laparoscopic pancreaticoduodenectomy: a center’s preliminary experience

Background The present study aims to assess the preliminary outcomes of the effectiveness of wrapping the ligamentum teres hepatis (LTH) around the gastroduodenal artery stump for the prevention of erosion hemorrhage after laparoscopic pancreaticoduodenectomy (LPD). Methods We reviewed 247 patients who had undergone LPD between January 2016 and April 2019. The patients were divided into two groups according to whether LTH wrapped the stump of the gastroduodenal artery: group A (119 patients) who underwent the LTH wrapping procedure, and group B (128 patients) who did not undergo the procedure. The perioperative data from the two groups were reviewed to assess the effectiveness of the LTH procedure for the prevention of postpancreatectomy hemorrhage (PPH) and other complications. Results No differences were observed in the clinical characteristics between the two groups. The data from 247 patients were acceptable for analysis: 119 patients underwent wrapping, and 128 patients did not. The incidence of clinically relevant pancreatic fistula (8.4% vs 3.9%), biliary fistula (2.5% vs 1.6%), intra-abdominal infection (10.1% vs 3.9%) and delayed gastric emptying (13.4% vs 16.4%) showed no significant difference between group A and group B. The 90-day mortality and 90-day reoperation rates (0.8% vs 0.8% and 5.0% vs 3.1%) were also similar between group A and group B. Furthermore, postpancreatectomy hemorrhage of Grade B and C occurred in 0 patients (0.0%) in the wrapping group, which was significantly less frequent than the occurrence in the nonwrapping group (7 patients; 5.5%, P = 0.02). Conclusions Wrapping the LTH around the gastroduodenal artery stump after LPD does not reduce the incidence of clinically relevant pancreatic fistula, biliary fistula or delayed gastric emptying. However, this procedure has a trend of reducing the rate of PPH of Grade B and C after LPD and is simple to perform.

Management of Postpancreatectomy Hemorrhage Following Pancreaticoduodenectomy at a Tertiary Care Center in Nepal

Introduction Postpancreatectomy hemorrhage (PPH) is an important complication which significantly increases morbidity and mortality following pancreaticoduodenectomy (PD). This study aims to find the incidence, classification, management, and mortality associated with PPH following PD. This study also describes the changes in management and outcomes between the period of 2004-2014 and 2015-2019 in our institute as in the later time period there was use of CT angiography and interventional radiology (IR) to identify and control the bleeding site. MethodsThis is a retrospective study in which medical records of patients having PPH following PD between 2004-2019 were analyzed. The grading and classification were done according to the International Study Group of Pancreatic Surgery (ISGPS). Management and outcomes were analyzed using standard descriptive statistics. ResultsA total of 43 patients developed PPH out of 336 PDs. Out of 43 patients, 4 (9.3%) had Grade A, 16 (37.2%) had Grade B and 23 (53.5%) had Grade C PPH. Fifteen (35%) patients were managed conservatively, seven (16.2%) with IR procedure and 21 (48.8%) were reexplored. There were 16 (37.2%) mortalities, out of different factors- intraoperative blood loss >500 ml showed the predictability for mortality (p= 0.01). On comparing two time periods it was seen that the PPH rate was almost similar but the mortality decreased from 58.8% to 23.07%. ConclusionPPH following PD is associated with high mortality. Increased use of IR procedure and CT angiography can decrease the relaparotomy rates and eventually decrease mortality.

Wrapping the Stump of the Gastroduodenal Artery Using the Ligamentum Teres Hepatis During Laparoscopic Pancreaticoduodenectomy – A Center’s Preliminary Experience

Background: The present study aims to assess the preliminary outcomes of the effectiveness of wrapping the ligamentum teres hepatis (LTH) around the gastroduodenal artery stump for the prevention of erosion hemorrhage after laparoscopic pancreaticoduodenectomy (LPD).Methods: We reviewed 247 patients who had undergone LPD between January 2016 and April 2019. The patients were divided into 2 groups according to whether LTH wrapped the stump of the gastroduodenal artery: group A (119 patients) who underwent the LTH wrapping procedure, and group B (128 patients) who did not undergo the procedure. The perioperative data from the two groups were reviewed to assess the effectiveness of the LTH procedure for the prevention of postpancreatectomy hemorrhage (PPH) and other complications.Results: No differences were observed in the clinical characteristics between the 2 groups. The data from 247 patients were acceptable for analysis: 119 patients underwent wrapping, and 128 patients did not. The incidence of clinically relevant pancreatic fistula (8.4% vs 3.9%), biliary fistula (2.5% vs 1.6%), intra-abdominal infection (10.1% vs 3.9%) and delayed gastric emptying (13.4% vs 16.4%) showed no significant difference between group A and group B. The 90-day mortality and 90-day reoperation rates (0.8% vs 0.8% and 5.0% vs 3.1%) were also similar between group A and group B. Furthermore, postpancreatectomy hemorrhage of Grade B and C occurred in 0 patients (0.0%) in the wrapping group, which was significantly less frequent than the occurrence in the nonwrapping group (7 patients; 5.5%, P=0.02).Conclusions: Wrapping the LTH around the gastroduodenal artery stump after LPD does not reduce the incidence of clinically relevant pancreatic fistula, biliary fistula or delayed gastric emptying. However, this procedure has a trend of reducing the rate of PPH of Grade B and C after LPD and is simple to perform.