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

Abstract

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.

Evaluation of Open Surgical and Endovascular Treatment Options for Visceral Artery Erosions after Pancreatitis and Pancreatic Surgery

“…For example, a stent-graft has to be considered if the erosion occurs in the main celiac or superior mesenteric artery because of the possible consequences of liver or bowel ischemia after occlusion of the main artery [6,22,23,27]. On the other hand, endovascular coiling or embolization may be sufficient if the erosion occurs in the branches of the main arteries [28][29][30][31]. However, recurrent bleeding can occur in up to 21% of the patient after endovascular management [32].…”

Cross-sectional imaging after pancreatic surgery: The dialogue between the radiologist and the surgeon

“…The most frequently involved peripancreatic vascular structures are the gastroduodenal artery stump, followed by the splenic artery, the inferior pancreaticoduodenal artery, the splenic vein stump, or the intrapancreatic arteries [33] , [34] , [35] , [36] . Other common sites of PPH include the anastomoses suture lines (i.e., gastro-enteric, duodenal-enteric, jejunal-jejunal, or pancreatic-enteric anastomoses), the resection area (i.e., pancreas stump, retroperitoneum), or a ruptured pseudoaneurysm that has developed [37] , [38] , [39] .…”