Backgrounds/Aims: The course of severe acute pancreatitis (SAP) complicated by hemorrhage is associated with poor outcome. Methods: Twenty-four (13%) out of 183 cases of SAP had hemorrhagic complications-12 intraabdominal & 12 intraluminal, 13 had major & 11 had minor and 16 had de-novo & 8 post-surgical bleeding. The mean duration of pancreatitis prior to bleeding was 27±27.2 days. Results: Predictors of haemorrhage on univariate analysis were delayed admission (0.037), more than one organ failure (p=0.008), presence of venous thrombosis (p=0.033), infective necrosis (0.001) and systemic sepsisbacterial (0.037) & fungal (p=0.032). On multivariate analysis infected necrosis (OR=11.82) and presence of fungal sepsis (OR=3.73) were the significant factors. Patients presenting with more than one organ failure and bacterial sepsis had borderline significance on multivariate analysis. Need for surgery (50% vs. 12.6%), intensive care stay (7.4±7.9 vs. 5.4±5.2 days) and mortality (41.7% vs. 10.7%) were significantly higher in patients who suffered haemorrhage. Seven of the 13 with major bleeding had pseudoaneurysms-4 were embolized, 4 needed surgery including 1 embolization failure. Seven with intraabdominal bleeding required surgical intervention, 2 had successful embolization and 3 had expectant management. CT severity index and surgical intervention, were significantly associated with intraabdominal bleeding. Organ failure, presence of pseudoaneurysm and surgical intervention were associated with major bleeding. Conclusions: Hemorrhage in SAP was associated with increased morbidity and mortality. Infected necrosis accentuated the degradation of the vessel wall, which predispose to hemorrhage. Luminal bleeding may be indicative of erosion into the adjacent viscera by the pseudoaneurysm.

A meticulously performed hepatic arterial anastomosis with long-term patency is 1 of the cornerstones of successful liver transplantation. Multiple arterial anastomoses, small-caliber hepatic arteries, and unhealthy arteries secondary to atherosclerosis or prior arterial interventions such as transarterial chemoembolization (TACE) are recognized risk factors for hepatic artery thrombosis (HAT). Arterial inflow during living donor liver transplantation (LDLT) is complicated by the small size of the graft arteries. Inflow in these cases is usually achieved through the recipient right hepatic artery (RHA), left hepatic artery (LHA), or proper hepatic artery (PHA) to achieve a size-matched anastomosis.Subintimal dissection of the hepatic artery (SDA) can occur during recipient hepatectomy as a result of atherosclerotic recipient arteries, difficult hilar dissection in the setting of severe portal hypertension, or previous TACE. Alternate size-matched arteries in close vicinity of the liver graft are needed to complete arterial reconstruction. The proximal gastroduodenal artery (GDA), right gastroepiploic artery, left gastric artery, or splenic artery are the most common reported alternatives to deal with this problem. (1,2) We have used distal GDA inflow as the first choice for arterial reconstruction when there is extensive dissection of the common hepatic artery (CHA) extending proximal to the GDA. The technique is based on how SDA progresses and the ability of the distal GDA to provide sufficient arterial inflow through the pancreaticoduodenal arcade. We report our experience of using this novel technique in 9 patients undergoing LDLT who developed intraoperative SDA.

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