Two forms of one complication

Abstract

Postpancreatectomy hemorrhage (PPH) remains a rare but lethal complication following laparoscopic pancreaticoduodenectomy (LPD) in the modern era of advanced surgical techniques. The main reason for early PPH (within 24 hours following surgery) has been found to be a failure of hemostasis during the surgical procedure. The reasons for late PPH tend to be variate. Positive associations have been identified between late PPH and intraabdominal erosive factors such as postoperative pancreatic fistula, bile leakage, gastrointestinal fistula, and intraabdominal infection. Still, some patients suffer PPH who do not have these erosive factors. The severity of bleeding and clinical prognosis of erosive and nonerosive PPH following LPD is different. We analyzed the electronic clinical records of 33 consecutive patients undergoing LPD and experiencing one or more episodes of hemorrhage after postoperative day 1 in this study. All patients received an LPD with standard lymphadenectomy. The patient's hemorrhage-related information was extracted, such as interval from surgery to bleeding, presentation, bleeding site, severity, management, and clinical prognosis. Based on our clinical practice, we proposed a treatment strategy for these 2 forms of late PPH following LPD. Of these 33 patients, 8 patients (24.24%) developed nonerosive bleeding, and other 25 patients (75.76%) suffered from postoperative hemorrhage caused by various intraabdominal erosive factors. The median interval from the LPD surgery to postoperative hemorrhage for both groups was 11 days, and no significant differences were found ( P = .387). For patients with erosive bleeding, most (60%) underwent their episodes of bleeding on postoperative days 5 to 14. For patients with nonerosive bleeding, most (75%) began postoperative hemorrhage 2 weeks after surgery, and 50% of these patients had bleeding between postoperative days 20 and 30. In the present study, 64% (16/25) of patients with erosive bleeding and 87.5% (7/8) of patients with nonerosive bleeding had internal bleeding. The fact that 90% (9/10) of all gastrointestinal bleeding patients had intraabdominal erosive factors indicated strong relationships between gastrointestinal hemorrhage and these erosive factors. The bleeding sites were detected in most patients, except for 4 patients who received conservative treatments. For patients with erosive bleeding, the most common bleeding site detected was the pancreatic remnant (43.48%); others included the hepatic artery (39.13%), splenic artery (13.04%), and left gastric artery (4.35%). For patients with nonerosive bleeding, the most common bleeding site was the hepatic artery (83.33%), and the 2nd most frequent site was the splenic artery (16.67%). No hemorrhage from pancreaticojejunal anastomosis occurred in the patients with nonerosive bleeding. Statistical significance was noted between these 2 groups in hemorrhage severity ( P = .012), management strategies ( ...

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

“…Preoperative biliary drainage was performed in 121 patients (63%). Median length of stay was 8 (6)(7)(8)(9)(10)(11)(12) days in ICU/ICM and 15 (12)(13)(14)(15)(16)(17)(18)(19)(20)(21) days in hospital. Nine patients (4.7%) died within 90 days after surgery.…”

“…POPF diagnosis on postoperative day (POD) 3 is known to be an independent predictive factor of late PPH (22). Indeed, associations have been identified between late PPH and intra-abdominal erosive factors such as POPF, bile leakage, gastrointestinal fistula, and intra-abdominal infection (8). In this context, arterial bleeding caused by pseudoaneurysms accounts for a major part of PPH.…”

“…In this context, arterial bleeding caused by pseudoaneurysms accounts for a major part of PPH. Muscular arterial wall weakening could be triggered by abdominal drainage erosion or excessive surgical dissection, as suggested by Feng et al (8). Thus, DFAC is a well-known predictive factor for POPF (23).…”

Postpancreatectomy hemorrhage: classification, epidemiology, risk factors

“…У 3 из 6 пациентов в течение 12-72 ч произошел рецидив кровотечения. В другом исследовании, посвя щенном геморрагическим осложнениям после лапароскопической ПДР, частота сторожевого кровотечения составила 56% [12].…”

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

“…The main cause of early PPH is a physiologic or technical failure of hemostasis such as bleeding from an anastomosis, diffuse bleeding due to coagulopathy, or a slipped ligature or metal clip [ 1 , 3 ]. Late PPH is often associated with the presence of intraabdominal erosive factors such as anastomotic leaks and/or intraabdominal infections [ 8 ]. Late hemorrhage carries a significant mortality rate of 15–58% [ 3 ].…”