Postpancreatectomy haemorrhage (PPH), prevalence, diagnosis and management
Authors:
M. Loveček 1,2; P. Skalický 1,2; M. Köcher 3; M. Černá 3; V. Prášil 3; I. Holusková 4; H. Jugová 2; M. Chrástecká 2; T. Yogeswara 5; Č. Neoral 1,2; R. Vrba 1,2; D. Klos 1,2; R. Havlík 1,2
Authors‘ workplace:
I. chirurgická klinika FN Olomouc, přednosta: prof. MUDr. Č. Neoral, CSc.
1; I. chirurgická klinika LF Univerzity Palackého, Olomouc, přednosta: prof. MUDr. Č. Neoral, CSc.
2; Radiologická klinika FN Olomouc, přednosta: Prof. MUDr. M. Heřman, Ph. D.
3; Transfuzní oddělení FN Olomouc, primářka: MUDr. D. Galuszková, Ph. D., MBA
4; Hywel Dda University Health Board, Glangwili General Hospital, United Kingdom
5
Published in:
Rozhl. Chir., 2016, roč. 95, č. 9, s. 350-357.
Category:
Original articles
Overview
Introduction:
Postpancreatectomy haemorrhage (PPH) is considered to be the most severe specific postoperative complication following pancreatic resections and its treatment is difficult and requires coordinated interdisciplinary collaboration. PPH causes 11–38% of all post-pancreatectomy deaths. The aim of this study was to determine the prevalence of PPH in a set of patients operated on within the last 10 years, and to analyze the diagnostic methods, treatment modalities and the outcomes.
Methods:
A retrospective analysis of patients undergoing pancreatic resections between 2006 and 2015. Clinically relevant PPH (types B and C) were the subject of interest. The onset, location and severity of PPH were analysed. Other factors analysed included operation diagnosis of PPH, diagnostic methods along with signs of sentinel bleeding, treatment options undertaken including the number of transfusions. 30-day, 90-day and in-hospital mortality, as well as the length of hospital stay and readmission rate were calculated. A descriptive statistical method was used.
Results:
A total of 449 patients were operated on. Pancreatoduodenectomy (DPE) or pylorus-preserving pancreatoduodenectomy (PPPD) was done in 76.4%, left sided pancreatectomy (LPE) in 19.8% and total pancreatectomy (TPE) in 3.8%. 190 of the patients (42.3%) were women and 259 (57.7%) men, with the mean age of 61.5±11.1 years. A total of 23 (5.1%) PPH cases were identified, 21 (4.7%) were clinically relevant. Eight patients (35%) developed early PPH with direct reoperation, late PPH was seen in 14 patients after DPE and in one after LPE. Sentinel bleeding was present in 53.3% of late PPH cases. CT/CTA was performed in four patients with subsequent DSA performed in three. DSA identified a gastroduodenal artery stump pseudoaneurysm in one patient, which was resolved using a stent. Surgical intervention for late PPH was required in 10 patients in total, six of whom needed direct surgery due to the rapid development of circulatory instability and 3 due to inconclusive radiological management. One patient needed surgical drainage of both an abscess and haematoma. In two patients the origin of bleeding was due to a gastric ulcer, which was proven and solved endoscopically and 2 patients required conservative treatment only. The specific mortality for PPH was 17.4%. In the group of patients that suffered with any PPH following DPE and PPDPE the mortality rate was 22.2%, and 28.6% for late PPH. If late PPH developed coincidentally with postoperative pancreatic fistula (POPF), the mortality was 44%. In the early PPH group, an average of 10.1±2.5 transfusion units (TUs) were used with an average length of hospital stay 17.5±4.8 days and zero mortality in comparison to an average of 11.7±10 TUs and 29.9±14.6 days in hospital and 26.6% mortality in the late PPH group.
Conclusion:
PPH is a severe complication, which has a high mortality rate. It also often coincidentally develops with POPFs. Early clinical diagnosis with identification of its cause plays a key role in management. The use of interventional radiology in the treatment of PPH has begun to dominate other treatment modalities due to a very high success rate, and close collaboration with interventional radiologists is necessary in order to reduce the rate of surgical intervention required in PPH.
Key words:
haemorrhage – pancreas – resection – complications – mortality
Sources
1. Welsch T, Eisele H, Zschäbitz S, et al. Critical appraisal of the International Study Group of Pancreatic Surgery (ISGPS) consensus definition of postoperative hemorrhage after pancreatoduodenectomy. Langenbecks Arch Surg 2011;396:783−91.
2. Fong ZV, Correa-Gallego C, Ferrone CR, et al. Early drain removal – the middle ground between the drain versus no drain debate in patients undergoing pancreaticoduodenectomy. A prospective validation study. Ann Surg 2015;262:378−83.
3. Wente MN, Veit JA, Bassi C, et al. Postpancreatectomy hemorrhage (PPH) – an international study group of pancreatic surgery (ISGPS) definition. Surgery 2007;142:20−5.
4. DeOliveira ML, Winter JM, Schafer M, et al. Assessment of complications after pancreatic surgery: a novel grading system applied to 633 patients undergoing pancreaticoduodenectomy. Ann Surg 2006;244:931−7.
5. Bassi C, Dervenis C, Butturini G, et al. Postoperative pancreatic fistula: an international study group (ISGPF) definition. Surgery 2005;138:8−13.
6. Čečka F, Jon B, Šubrt Z, et al. Pankreatická píštěl – definice, rizikové faktory a možnosti léčby. Rozhl Chir. 2013;92:77−84.
7. Wente MN, Bassi C, Dervenis C, et al. Delayed gastric emptying (DGE) after pancreatic surgery: a suggested definition by the International Study Group of Pancreatic Surgery (ISGPS). Surgery 2007;142:761−8.
8. Grützmann R, Rückert F, Hippe-Davies N, et al. Evaluation of the International Study Group of Pancreatic Surgery definition of post-pancreatectomy hemorrhage in a high-volume center. Surgery 2012;151:612−20.
9. Čečka F, Jon B, Čermáková E, et al. Impact of postoperative complications on clinical and economic consequences in pancreatic surgery. Ann Surg Treat Res 2016;90:21−8.
10. Swanson RS, Pezzi CM, Mallin K, et al. The 90-day mortality after pancreatectomy for cancer is double the 30-day mortality: more than 20,000 resections from the national cancer data base. Ann Surg Oncol 2014;21:4059−67.
11. Alsfasser G, Leicht H, Günster C, et al. Volume-outcome relationship in pancreatic surgery. Br J Surg 2016;103:136−143.
12. Finks JF, Osborne NH, Birkmeyer JD. Trends in hospital volume and operative mortality for high-risk surgery. N Engl J Med 2011;364:2128–37.
13. Tien YW, Wu YM, Liu KL, et al. Angiography is indicated for every sentinel bleed after pancreaticoduodenectomy. Ann Surg Oncol 2008;15:1855−61.
14. Yekebas EF, Wolfram L, Cataldegirmen G, et al. Postpancreatectomy hemorrhage: diagnosis and treatment: an analysis in 1669 consecutive pancreatic resections. Ann Surg 2007;246:269−80.
15. Loveček M, Klos D, Skalický P, et al. Resekabilní karcinom pankreatu − 5leté přežití. Rozhl Chir 2015;94:470−6.
16. Merkow RP, Bilimoria KY, Tomlinson JS, et al. Postoperative complications reduce adjuvant chemotherapy use in resectable pancreatic cancer. Ann Surg 2014;260:372−7.
17. Wu W, He J, Cameron JL, et al. The impact of postoperative complications on the administration of adjuvant therapy following pancreaticoduodenectomy for adenocarcinoma. Ann Surg Oncol 2014;21:2873−81.
18. Oettle H, Post S, Neuhaus P, et al. Adjuvant chemotherapy with gemcitabine vs observation in patients undergoing curative-intent resection of pancreatic cancer: a randomized controlled trial. JAMA 2007;297:267−77.
19. Neoptolemos JP, Moore MJ, Cox TF, et al. Effect of adjuvant chemotherapy with fluorouracil plus folinic acid or gemcitabine vs observation on survival in patients with resected periampullary adenocarcinoma: the ESPAC-3 periampullary cancer randomized trial. JAMA. 2012;308:147−56.
20. Stampfl U, Hackert T, Sommer CM, et al. Superselective embolization for the management of postpancreatectomy hemorrhage: a single-center experience in 25 patients. J Vasc Interv Radiol 2012;23:504−10.
21. Limongelli P, Khorsandi SE, Pai M, et al. Management of delayed postoperative hemorrhage after pancreaticoduodenectomy: a meta-analysis. Arch Surg 2008;143:1001−7.
22. Santoro R, Carlini M, Carboni F, et al. Delayed massive arterial hemorrhage after pancreaticoduodenectomy for cancer. Management of a life-threatening complication. Hepatogastroenterology 2003;50:2199−2204.
23. Ricci C, Casadei R, Buscemi S, et al. Late postpancreatectomy hemorrhage after pancreaticoduodenectomy: is it possible to recognize risk factors? JOP 2012;13:193−8.
24. De Pietri L, Montalti R, Begliomini B. Anaesthetic perioperative management of patients with pancreatic cancer. World J Gastroenterol. 2014;20:2304–2320.
25. 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; 215:616–21.
26. Rajarathinam G, Kannan DG, Vimalraj V, et al. Post pancreaticoduodenectomy haemorrhage: outcome prediction based on new ISGPS Clinical severity grading. HPB, 2008;10:363–70.
27. Wellner UF, Kulemann B, Lapshyn H, et al. Postpancreatectomy hemorrhage – incidence, treatment and risk factors in over 1000 pancreatic resections. J Gastrointest Surg. 2014; 8:464–75.
28. Tien YW, Lee PH, Yang CY, et. al. Risk factors of massive bleeding related to pancreatic leak after pancreaticoduodenectomy. J Am Coll Surg. 2005;201:554–59.
29. De Castro SM, Kuhlmann KF, Busch OR et al. Delayed massive hemorrhage after pancreatic and biliary surgery: embolization or surgery? Ann Surg. 2005;241:85–91.
30. Khalsa BS, Imagawa DK, Chen JI, et al. Evolution in the treatment of delayed postpancreatectomy hemorrhage: Surgery to interventional radiology. Pancreas. 2015;44:953–58.
31. Tol JA, Busch OR, van Delden, et al. Shifting role of operative and nonoperative interventions in managing complications after pancreatoduodenectomy: what is the preferred intervention? Surgery. 2014;156:622–31.
32. Pastor J, Pádr R. Krvácení z pseudoaneuryzmatu a. hepatica po pankreatoduodenektomii řešené implantací stentgraftu. Rozhl Chir 2015;94:256–60.
33. Loveček M, Havlík R, Köcher M, et al. Pseudoaneurysm of the gastroduodenal artery following pancreatoduodenectomy. Stenting for hemorrhage. Wideochir Inne Tech Maloinwazyjne. 2014;9:297–301.
34. Wang MQ, Liu FY, Duan F, et al. Stent-grafts placement for treatment of massive hemorrhagie from ruptured hepatic artery after pancreaticoduodenenctomy. World J Gastroenterol. 2010;16:3716–22.
35. Lee HG, Heo JS, Choi SH, et al. Management of bleeding from pseudoaneurysms following pancreaticoduodenectomy. World J Gastroenterol. 2010;16:1239–44.
36. Darnis B, Lebau R, Chopin-Laly X, et. al. Postpancreatetomy hemorrhage (PPH): predictors and management from a prospective database. Langenbecks Arch Surg. 2013;398:441–48.
37. Roulin D, Cerantola Y, Demartines N, et al. Systematic review of delayed postoperative hemorrhage after pancreatic resection. J Gastrointest Surg. 2011;15:1055–62.
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Surgery Orthopaedics Trauma surgeryArticle was published in
Perspectives in Surgery
2016 Issue 9
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