Late Postpancreaticoduodenectomy Hemorrhage: Incidence, Risk Factors, Management and Outcome

Abstract

Background:Postpancreaticoduodenectomy (PD) hemorrhage (PPH) is a life-threatening complication after PD. The main objective of this study was to evaluate incidence and factors associated with late PPH as well as the management strategy and outcomes. Methods: Between May 2017 and March 2020, clinical data from 192 patients undergoing PD were collected prospectively in the CHIRPAN Database (NCT02871336) and retrospectively analyzed. In our institution, all patients scheduled for a PD are routinely admitted for monitoring and management in intensive/intermediate care unit (ICU/IMC). Results: The incidence of late PPH was 17% (32 of 192), whereas the 90-day mortality rate of late PPH was 19% (6 of 32). Late PPH was associated with 90-day mortality (P = 0.001). Using multivariate analysis, independent risk factors for late PPH were postoperative sepsis (P = 0.036), and on day 3, creatinine (P = 0.025), drain fluid amylase concentration (P = 0.023), lipase concentration (P < 0.001), and C-reactive protein (CRP) concentration (P < 0.001). We developed two predictive scores for PPH occurrence, the PANCRHEMO scores. Score 1 was associated with 68.8% sensitivity, 85.6% specificity, 48.8% predictive positive value, 93.2% negative predictive value, and an area under the receiver operating characteristic curves of 0.841. Score 2 was associated with 81.2% sensitivity, 76.9% specificity, 41.3% predictive positive value, 95.3% negative predictive value, and an area under the receiver operating characteristic curve of 0.859. Conclusions: Routine ICU/IMC monitoring might contribute to a better management of these complications. Some predicting factors such as postoperative sepsis and biological markers on day 3 should help physicians to determine patients requiring a prolonged ICU/IMC monitoring.

Hemorrhage Sites and Mitigation Strategies After Pancreaticoduodenectomy

“…Six primary PPH events (6.7%) occurred early, and none were from the GDA (Table 3). Patients with primary GDA hemorrhage had a longer median (IQR) time between surgery and manifestation of bleeding (21 days [15-26] vs 10 days [5][6][7][8][9][10][11][12][13][14][15][16][17][18]; P = .002) and were more likely to be evaluated angiographically (14 [93.3%] vs 45 [60%]; P = .05). Rates of secondary PPH, anastomotic leaks, total LOS, and 90-day mortality were similar between groups.…”

“…The International Study Group of Pancreatic Surgery (ISGPS) classified PPH according to onset (early ≤24 hours or late >24 hours), location (intraluminal or extraluminal), and severity (grades A, B, and C) . Grade C PPH, the most severe form, occurs late, compromises hemodynamics, necessitates product transfusion, and requires invasive evaluation and/or intervention …”

“…Of all hemorrhage events (n = 117), the gastroduodenal artery was the source in 19 (16.2%, 0.63% incidence in all pancreaticoduodenectomies). Gastroduodenal artery hemorrhage was more often associated with soft gland texture (14 [93.3%] vs 41 [62.1%]; P = .02) and later presentation (median [IQR],[21][22][23][24][25][26] vs 10 days [5][6][7][8][9][10][11][12][13][14][15][16][17][18]; P = .002). Twenty-three patients underwent empirical gastroduodenal artery embolization or stent placement, 7 (30.4%) of whom subsequently experienced secondary hemorrhage.…”

“…5 Grade C PPH, the most severe form, occurs late, compromises hemodynamics, necessitates product transfusion, and requires invasive evaluation and/or intervention. [5][6][7][8] Early PPH often occurs extraluminally and is attributed to technical error or failure of intended hemostasis. 4,5 Late PPH manifests either extraluminally or intraluminally and is often associated with postoperative pancreatic fistula (POPF) and its attendant risk factors.…”

Predicting patient outcomes after major abdominal surgery: the role of shock index and heart rate

“…Postoperative complications prolong hospital stay, increase healthcare costs, and mortality [1]. Therefore, there is an increased interest in the early detection of postoperative complications to allow timely management of the complications which would reduce organ failure and improve the overall patient prognosis [2].…”