Diagnostic and therapeutic strategy for postpancreaticoduodenectomy hemorrhage–experience of a single center_CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY

Authors：

WU Chuntao , LIU Liang , XU Huaxiang , XU Jin , LIU Chen , LONG Jiang , WANG Wenquan , NI Quanxing ,  YU Xianjun

Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center; Department of Oncology, Shanghai Medical College, Fudan University; Pancreatic Cancer Institute, Fudan University, Shanghai, P.R.China;

Corresponding author：

YU Xianjun, Email: yuxianjun@fudanpci.org

Keywords：

postpancreaticoduodenectomy hemorrhage; sentinel bleeding; diagnosis and treatment

DOI：

10.7507/1007-9424.201704058

Video：

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Objective To investigate the cause, treatment, and prognosis of the postpancreaticoduodenectomy hemorrhage (PPH) . Method A total of 779 patients who underwent pancreaticoduodenectomy at Fudan University Shanghai Cancer Center between January 2015 and December 2016 were enrolled, and the data of them were retrospectively analyzed. Results Sixteen patients (PPH group) suffered from PPH and 763 patients didn’t suffered from PPH (non-PPH group) of 779 patients. There was no significant difference in the age, gender, type of disease, operative time, blood loss, and ratio of blood transfusion between the 2 groups (P>0.05), but the incidences of pancreatic fistula and delayed gastric emptying, postoperative drainage time, hospital stay, and mortality were all higher or longer in PPH group compared with non-PPH group (P<0.001). Of the 16 PPH patients, early haemorrhage occurred in 3 patients (including 2 patients with gastrointestinal haemorrhage and 1 patient with intra-abdominal haemorrhage) and delayed haemorrhage occurred in 13 patients (including 6 patients with gastrointestinal haemorrhage and 7 patients with intra-abdominal haemorrhage). All the 3 patients with early haemorrhage were cured by surgery. Of the 13 patients with delayed haemorrhage, 5 patients were cured by radiological intervention, 2 patients were cured by endoscopic hemostasis, and 3 patients were cured by conservative treatment, but 3 patients with sentinel bleeding died after interventional embolization+surgery. Conclusions The mortality of PPH is high. Surgery is optimal to early haemorrhage and radiological intervention is optimal to delayed haemorrhage, including embolization or covered stent implantation. The sentinel bleeding should be given great attention.

Citation： WU Chuntao, LIU Liang, XU Huaxiang, XU Jin, LIU Chen, LONG Jiang, WANG Wenquan, NI Quanxing, YU Xianjun. Diagnostic and therapeutic strategy for postpancreaticoduodenectomy hemorrhage–experience of a single center. CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY, 2017, 24(6): 680-684. doi: 10.7507/1007-9424.201704058 Copy

1.	Darnis B, Lebeau R, Chopin-Laly X, et al. Postpancreatectomy hemorrhage (PPH): predictors and management from a prospective database. Langenbecks Arch Surg, 2013, 398(3): 441-448.
2.	Yekebas EF, Wolfram L, Cataldegirmen G, et al. Postpancreatectomy hemorrhage: diagnosis and treatment: an analysis in 1 669 consecutive pancreatic resections. Ann Surg, 2007, 246(2): 269-280.
3.	Dusch N, Lietzmann A, Barthels F, et al. International study group of pancreatic surgery definitions for postpancreatectomy complications: applicability at a high-volume center. Scand J Surg, 2017, [Epub ahead of print].
4.	Romano G, Agrusa A, Galia M, et al. Whipple's pancreaticoduodenectomy: Surgical technique and perioperative clinical outcomes in a single center. Int J Surg, 2015, 21 Suppl 1: S68-S71.
5.	Wellner UF, Kulemann B, Lapshyn H, et al. Postpancreatectomy hemorrhage--incidence, treatment, and risk factors in over 1,000 pancreatic resections. J Gastrointest Surg, 2014, 18(3): 464-475.
6.	Dardik H. Postpancreatectomy hemorrhage. J Am Coll Surg, 2013, 216(3): 508-509.
7.	Gaudon C, Soussan J, Louis G, et al. Late postpancreatectomy hemorrhage: predictive factors of morbidity and mortality after percutaneous endovascular treatment. Diagn Interv Imaging, 2016, 97(11): 1071-1077.
8.	Liu C, Long J, Liu L, et al. Pancreatic stump-closed pancreaticojejunostomy can be performed safely in normal soft pancreas cases. J Surg Res, 2012, 172(1): e11-e17.
9.	Mohammed S, Van Buren Ii G, McElhany A, et al. Delayed gastric emptying following pancreaticoduodenectomy: Incidence, risk factors, and healthcare utilization. World J Gastrointest Surg, 2017, 9(3): 73-81.
10.	Ahmad SA, Edwards MJ, Sutton JM, et al. Factors influencing readmission after pancreaticoduodenectomy: a multi-institutional study of 1302 patients. Ann Surg, 2012, 256(3): 529-537.
11.	Hanna MM, Gadde R, Allen CJ, et al. Delayed gastric emptying after pancreaticoduodenectomy. J Surg Res, 2016, 202(2): 380-388.
12.	Malleo G, Vollmer CM Jr. Postpancreatectomy complications and management. Surg Clin North Am, 2016, 96(6): 1313-1336.
13.	Correa-Gallego C, Brennan MF, D'Angelica MI, et al. Contemporary experience with postpancreatectomy hemorrhage: results of 1,122 patients resected between 2006 and 2011. J Am Coll Surg, 2012, 215(5): 616-621.
14.	Ricci C, Casadei R, Buscemi S, et al. Late postpancreatectomy hemorrhage after pancreaticoduodenectomy: is it possible to recognize risk factors? JOP, 2012, 13(2): 193-198.
15.	Wente MN, Veit JA, Bassi C, et al. Postpancreatectomy hemorrhage (PPH): an International Study Group of Pancreatic Surgery (ISGPS) definition. Surgery, 2007, 142(1): 20-25.
16.	Khalsa BS, Imagawa DK, Chen JI, et al. Evolution in the treatment of delayed postpancreatectomy hemorrhage: surgery to interventional radiology. Pancreas, 2015, 44(6): 953-958.
17.	Jagad RB, Koshariya M, Kawamoto J, et al. Postoperative hemorrhage after major pancreatobiliary surgery: an update. Hepatogastroenterology, 2008, 55(82-83): 729-737.
18.	Ellison EC. Evidence-based management of hemorrhage after pancreaticoduodenectomy. Am J Surg, 2007, 194(1): 10-12.
19.	Mita K, Ito H, Takahashi K, et al. Postpancreatectomy hemorrhage after pancreatic surgery in patients receiving anticoagulation or antiplatelet agents. Surg Innov, 2016, 23(3): 284-290.
20.	Roulin D, Cerantola Y, Demartines N, et al. Systematic review of delayed postoperative hemorrhage after pancreatic resection. J Gastrointest Surg, 2011, 15(6): 1055-1062.
21.	Hassold N, Wolfschmidt F, Dierks A, et al. Effectiveness and outcome of endovascular therapy for late-onset postpancreatectomy hemorrhage using covered stents and embolization. J Vasc Surg, 2016, 64(5): 1373-1383.
22.	Heiss P, Bachthaler M, Hamer OW, et al. Delayed visceral arterial hemorrhage following Whipple's procedure: minimally invasive treatment with covered stents. Ann Surg Oncol, 2008, 15(3): 824-832.
23.	Stoupis C, Ludwig K, Inderbitzin D, et al. Stent grafting of acute hepatic artery bleeding following pancreatic head resection. Eur Radiol, 2007, 17(2): 401-408.
24.	Koukoutsis I, Bellagamba R, Morris-Stiff G, et al. Haemorrhage following pancreaticoduodenectomy: risk factors and the importance of sentinel bleed. Dig Surg, 2006, 23(4): 224-228.
25.	Treckmann J, Paul A, Sotiropoulos GC, et al. Sentinel bleeding after pancreaticoduodenectomy: a disregarded sign. J Gastrointest Surg, 2008, 12(2): 313-318.
26.	Tien YW, Wu YM, Liu KL, et al. Angiography is indicated for every sentinel bleed after pancreaticoduodenectomy. Ann Surg Oncol, 2008, 15(7): 1855-1861.

1. Darnis B, Lebeau R, Chopin-Laly X, et al. Postpancreatectomy hemorrhage (PPH): predictors and management from a prospective database. Langenbecks Arch Surg, 2013, 398(3): 441-448.
2. Yekebas EF, Wolfram L, Cataldegirmen G, et al. Postpancreatectomy hemorrhage: diagnosis and treatment: an analysis in 1 669 consecutive pancreatic resections. Ann Surg, 2007, 246(2): 269-280.
3. Dusch N, Lietzmann A, Barthels F, et al. International study group of pancreatic surgery definitions for postpancreatectomy complications: applicability at a high-volume center. Scand J Surg, 2017, [Epub ahead of print].
4. Romano G, Agrusa A, Galia M, et al. Whipple's pancreaticoduodenectomy: Surgical technique and perioperative clinical outcomes in a single center. Int J Surg, 2015, 21 Suppl 1: S68-S71.
5. Wellner UF, Kulemann B, Lapshyn H, et al. Postpancreatectomy hemorrhage--incidence, treatment, and risk factors in over 1,000 pancreatic resections. J Gastrointest Surg, 2014, 18(3): 464-475.
6. Dardik H. Postpancreatectomy hemorrhage. J Am Coll Surg, 2013, 216(3): 508-509.
7. Gaudon C, Soussan J, Louis G, et al. Late postpancreatectomy hemorrhage: predictive factors of morbidity and mortality after percutaneous endovascular treatment. Diagn Interv Imaging, 2016, 97(11): 1071-1077.
8. Liu C, Long J, Liu L, et al. Pancreatic stump-closed pancreaticojejunostomy can be performed safely in normal soft pancreas cases. J Surg Res, 2012, 172(1): e11-e17.
9. Mohammed S, Van Buren Ii G, McElhany A, et al. Delayed gastric emptying following pancreaticoduodenectomy: Incidence, risk factors, and healthcare utilization. World J Gastrointest Surg, 2017, 9(3): 73-81.
10. Ahmad SA, Edwards MJ, Sutton JM, et al. Factors influencing readmission after pancreaticoduodenectomy: a multi-institutional study of 1302 patients. Ann Surg, 2012, 256(3): 529-537.
11. Hanna MM, Gadde R, Allen CJ, et al. Delayed gastric emptying after pancreaticoduodenectomy. J Surg Res, 2016, 202(2): 380-388.
12. Malleo G, Vollmer CM Jr. Postpancreatectomy complications and management. Surg Clin North Am, 2016, 96(6): 1313-1336.
13. Correa-Gallego C, Brennan MF, D'Angelica MI, et al. Contemporary experience with postpancreatectomy hemorrhage: results of 1,122 patients resected between 2006 and 2011. J Am Coll Surg, 2012, 215(5): 616-621.
14. Ricci C, Casadei R, Buscemi S, et al. Late postpancreatectomy hemorrhage after pancreaticoduodenectomy: is it possible to recognize risk factors? JOP, 2012, 13(2): 193-198.
15. Wente MN, Veit JA, Bassi C, et al. Postpancreatectomy hemorrhage (PPH): an International Study Group of Pancreatic Surgery (ISGPS) definition. Surgery, 2007, 142(1): 20-25.
16. Khalsa BS, Imagawa DK, Chen JI, et al. Evolution in the treatment of delayed postpancreatectomy hemorrhage: surgery to interventional radiology. Pancreas, 2015, 44(6): 953-958.
17. Jagad RB, Koshariya M, Kawamoto J, et al. Postoperative hemorrhage after major pancreatobiliary surgery: an update. Hepatogastroenterology, 2008, 55(82-83): 729-737.
18. Ellison EC. Evidence-based management of hemorrhage after pancreaticoduodenectomy. Am J Surg, 2007, 194(1): 10-12.
19. Mita K, Ito H, Takahashi K, et al. Postpancreatectomy hemorrhage after pancreatic surgery in patients receiving anticoagulation or antiplatelet agents. Surg Innov, 2016, 23(3): 284-290.
20. Roulin D, Cerantola Y, Demartines N, et al. Systematic review of delayed postoperative hemorrhage after pancreatic resection. J Gastrointest Surg, 2011, 15(6): 1055-1062.
21. Hassold N, Wolfschmidt F, Dierks A, et al. Effectiveness and outcome of endovascular therapy for late-onset postpancreatectomy hemorrhage using covered stents and embolization. J Vasc Surg, 2016, 64(5): 1373-1383.
22. Heiss P, Bachthaler M, Hamer OW, et al. Delayed visceral arterial hemorrhage following Whipple's procedure: minimally invasive treatment with covered stents. Ann Surg Oncol, 2008, 15(3): 824-832.
23. Stoupis C, Ludwig K, Inderbitzin D, et al. Stent grafting of acute hepatic artery bleeding following pancreatic head resection. Eur Radiol, 2007, 17(2): 401-408.
24. Koukoutsis I, Bellagamba R, Morris-Stiff G, et al. Haemorrhage following pancreaticoduodenectomy: risk factors and the importance of sentinel bleed. Dig Surg, 2006, 23(4): 224-228.
25. Treckmann J, Paul A, Sotiropoulos GC, et al. Sentinel bleeding after pancreaticoduodenectomy: a disregarded sign. J Gastrointest Surg, 2008, 12(2): 313-318.
26. Tien YW, Wu YM, Liu KL, et al. Angiography is indicated for every sentinel bleed after pancreaticoduodenectomy. Ann Surg Oncol, 2008, 15(7): 1855-1861.

CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY

Diagnostic and therapeutic strategy for postpancreaticoduodenectomy hemorrhage–experience of a single center

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