Postpancreatectomy hemorrhage (PPH): predictors and management from a prospective database

Darnis, Benjamin; Lebeau, R; Chopin-Laly, Xavier; Adham, Mustapha

doi:10.1007/s00423-013-1047-8

Cited by 88 publications

(95 citation statements)

References 24 publications

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“…In cases where hemodynamic stability is preserved, the first actions are monitoring the patient's hemodynamic levels and drains. Darnis et al (8) stated that in their case series of 285 cases with hemorrhage, the hemorrhages were stopped with a medical approach in 32% of cases; in 68% of cases, intervention (surgical, endoscopic, or embolization) was needed (9). In our series, CT angiography was performed in seven cases; hemorrhage from the portal vein was found in two cases, from the gastroduodenal artery in one case, and from the pancreatic artery in one case.…”

Section: Discussionmentioning

confidence: 63%

“…Tani et al (12) defined male gender, prolonged surgery, and blood transfusion as independent risk factors. Some studies report that parameters such as prolonged hospital stay, ERCP and stenting, the presence of preoperative jaundice, trauma/resection of the splenic vessels, additional surgical procedures, older age, the presence of intraabdominal infection, and nutritional risk index are factors that increase the risk of hemorrhage (2,(7)(8)(9)(12)(13)(14). Most of the factors mentioned above are present in our series (Table 1).…”

Section: Discussionmentioning

confidence: 69%

“…In Grade A patients, a conservative approach is more frequently performed in the foreground, whereas in Grade B and C patients, additional processes are required to identify the localization of the hemorrhage. Nasogastric tube (35%), decrease in hemoglobin level (17%), hemodynamic instability (15%), blood coming out of the drains (11%), and the presence of melena (9%) may be helpful to determine the diagnosis and the source of bleeding (8). The source of bleeding can be determined by computerized tomography (CT) angiography in half of these cases (8).…”

Section: Discussionmentioning

confidence: 99%

“…Nasogastric tube (35%), decrease in hemoglobin level (17%), hemodynamic instability (15%), blood coming out of the drains (11%), and the presence of melena (9%) may be helpful to determine the diagnosis and the source of bleeding (8). The source of bleeding can be determined by computerized tomography (CT) angiography in half of these cases (8). In cases where hemodynamic stability is preserved, the first actions are monitoring the patient's hemodynamic levels and drains.…”

Section: Discussionmentioning

confidence: 99%

“…We also use somatostatin analogs routinely in our patients with fistulas. Soft pancreatic texture, thinness of the pancreatic duct, and the presence of fistulas are defined as major risk factors for hemorrhage (8). Tani et al (12) defined male gender, prolonged surgery, and blood transfusion as independent risk factors.…”

Section: Discussionmentioning

confidence: 99%

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Postoperative hemorrhage complications after the Whipple procedure

Dılek

Özşay²,

Acar³

et al. 2018

Turk J Surg

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Introduction:The Whipple operation is an essential surgical technique; however, its high morbidity (30% to 60%) and mortality (5%) rates are problems that should be addressed. The incidence of postoperative hemorrhage is 5% to 16% in the literature. In this study, the data and results in our clinic regarding postoperative hemorrhage complications were evaluated. Material and Methods:The files of 185 patients who underwent the Whipple operation in our hospital in the last five years were evaluated retrospectively, and we attempted to determine the causes of hemorrhage. It was found that 13 (7%) patients experienced hemorrhage, and six of them were found to have died. In six of these cases, hemorrhage occurred due to fistulas from the portal vein, gastroduodenal artery, and pancreatic arteries at variable periods. Two cases were found to have developed disseminated intravascular coagulation as a result of sepsis. Early intervention was performed in two cases who bled from the meso veins and in one case who bled from the portal vein. Laparotomy and hemostasis were performed on a patient who bled from the gastric anastomosis line. In a patient who had been taking low molecular weight heparin, bleeding from the drains and nasogastric tube stopped following cessation of the drug.Discussion: Preventive procedures such as connection of the vascular structures, use of vascular sealants, omental patching during surgery, and reducing the risk of complications by using somatostatin analogs were performed to prevent hemorrhages after Whipple surgeries. Results:In addition to known methods, angiography and embolization are emerging as effective methods in the diagnosis and treatment of hemorrhages. Furthermore, the determination and elimination of independent risk factors, such as jaundice, that affect fistula formation and bleeding in the perioperative period is important for prevention Keywords: Complication, hemorrhage, pancreas, treatment, Whipple operation INTRODUCTIONThe Whipple operation is an essential surgical technique for periampullary tumors; however, its high morbidity (30% to 60%) and mortality (5%) rates are problems that should be addressed (1-3). Pancreatic fistulas (2% to 62%) are among the most common complications after the Whipple procedure (1, 4). The incidence of postoperative hemorrhage is 5% to 20.2% in the literature. Mortality due to hemorrhage is reported as 15% to 58% (1, 5-7). Hemorrhages may arise from the suture lines in the early period; here, we evaluate the data and results from our clinic regarding postoperative hemorrhage problems in cases who developed infections and fistula in the days following surgery. MATERIAL AND METHODSThe files of 185 patients who underwent the Whipple operation in our hospital in the last five years (2011 to 2015) were evaluated retrospectively; we also attempted to determine the causes of hemorrhage. As a routine procedure, all patients signed consent forms containing information about the routine procedures and complications. Cases who had hemorrhoids, anal fiss...

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Section: Discussionmentioning

confidence: 63%

Section: Discussionmentioning

confidence: 69%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

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Postoperative hemorrhage complications after the Whipple procedure

Dılek

Özşay²,

Acar³

et al. 2018

Turk J Surg

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Hemorrhage Sites and Mitigation Strategies After Pancreaticoduodenectomy

Preston,

Collins,

Gönen

et al. 2024

JAMA Surg

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ImportancePostpancreatectomy hemorrhage is an uncommon but highly morbid complication of pancreaticoduodenectomy. Clinical evidence often draws suspicion to the gastroduodenal artery stump, even without a clear source.ObjectiveTo determine the frequency of gastroduodenal artery bleeding compared to other sites and the results of mitigation strategies.Design, Setting, and ParticipantsThis cohort study involved a retrospective analysis of data for consecutive patients who had pancreaticoduodenectomy from 2011 to 2021 at Memorial Sloan Kettering Cancer Center (MSK) and Thomas Jefferson University Hospital (TJUH).ExposuresDemographic, perioperative, and disease-related variables.Main Outcomes and MeasuresThe incidence, location, treatment, and outcomes of primary (initial) and secondary (recurrent) hemorrhage requiring invasive intervention were analyzed. Imaging studies were re-reviewed by interventional radiologists to confirm sites.ResultsInclusion criteria were met by 3040 patients (n = 1761 MSK, n = 1279 TJUH). Patients from both institutions were similar in age (median [IQR] age at MSK, 67 [59-74] years, and at TJUH, 68 [60-75] years) and sex (at MSK, 814 female [46.5%] and 947 male [53.8%], and at TJUH, 623 [48.7%] and 623 male [51.3%]). Primary hemorrhage occurred in 90 patients (3.0%), of which the gastroduodenal artery was the source in 15 (16.7%), unidentified sites in 24 (26.7%), and non–gastroduodenal artery sites in 51 (56.7%). Secondary hemorrhage occurred in 23 patients; in 4 (17.4%), the gastroduodenal artery was the source. 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 [15-26] vs 10 days [5-18]; P = .002). Twenty-three patients underwent empirical gastroduodenal artery embolization or stent placement, 7 (30.4%) of whom subsequently experienced secondary hemorrhage. Twenty percent of all gastroduodenal artery embolizations/stents (8/40 patients), including 13% (3/13 patients) of empirical treatments, were associated with significant morbidity (7 hepatic infarction, 4 biliary stricture), with a 90-day mortality rate of 38.5% (n = 5) for patients with these complications vs 7.8% without (n = 6; P = .008). Ninety-day mortality was 12.2% (n = 11) for patients with hemorrhage (3 patients [20%] with primary gastroduodenal vs 8 [10.7%] for all others; P = .38) compared with 2% (n = 59) for patients without hemorrhage.Conclusions and RelevanceIn this study, postpancreatectomy hemorrhage was uncommon and the spectrum was broad, with the gastroduodenal artery responsible for a minority of bleeding events. Empirical gastroduodenal artery embolization/stent without obvious sequelae of recent hemorrhage was associated with significant morbidity and rebleeding and should not be routine practice. Successful treatment of postpancreatectomy hemorrhage requires careful assessment of all potential sources, even after gastroduodenal artery mitigation.

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Outcomes following pancreatic surgery using three different thromboprophylaxis regimens

Hanna-Sawires

Groen

Klok

et al. 2019

British Journal of Surgery

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Background Postpancreatectomy haemorrhage (PPH) and venous thromboembolism (VTE) are serious complications following pancreatic surgery. The aim was to assess the timing, occurrence and predictors of PPH and VTE. Methods Elective pancreatic resections undertaken in a single university hospital between November 2013 and September 2017 were assessed. Three intervals were reviewed, each with a different routine regimen of nadroparin: 2850 units once daily (single dose) administered in hospital only, or 5700 units once daily (double dose) or 2850 units twice daily (split dose) administered in hospital and continued for 6 weeks after surgery. Clinically relevant PPH (CR‐PPH) was classified according to International Study Group of Pancreatic Surgery criteria. VTE was defined according to a number of key diagnostic criteria within 6 weeks of surgery. Cox regression analyses were performed to test the hypotheses that the double‐dose group would experience more PPH than the other two groups, the single‐dose group would experience more VTE than the other two groups, and the split‐dose group would experience the fewest adverse events (PPH or VTE). Results In total, 240 patients were included, 80 per group. The double‐dose group experienced significantly more CR‐PPH (hazard ratio (HR) 2·14, 95 per cent c.i. 1·16 to 3·94; P = 0·015). More relaparotomies due to CR‐PPH were performed in the double‐dose group (16 versus 3·8 per cent; P = 0·002). The single‐dose group did not experience more VTE (HR 1·41, 0·43 to 4·62; P = 0·570). The split dose was not associated with fewer adverse events (HR 0·77, 0·41 to 1·46; P = 0·422). Double‐dose low molecular weight heparin (LMWH), high BMI and pancreatic fistula were independent predictors of CR‐PPH. Conclusion A double dose of LMWH prophylaxis continued for 6 weeks after pancreatic resection was associated with a twofold higher rate of CR‐PPH, resulting in four times more relaparotomies. Patients receiving a single daily dose of LMWH in hospital only did not experience a higher rate of VTE.

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Postpancreatectomy hemorrhage (PPH): predictors and management from a prospective database

Cited by 88 publications

References 24 publications

Postoperative hemorrhage complications after the Whipple procedure

Postoperative hemorrhage complications after the Whipple procedure

Hemorrhage Sites and Mitigation Strategies After Pancreaticoduodenectomy

Outcomes following pancreatic surgery using three different thromboprophylaxis regimens

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