Postpancreaticoduodenectomy Haemorrhage

Lt Col Priya Ranjan

Scheme of Presentation

IntroductionDefinitionClassificationDiagnosisManagement

Pancreaticoduodenectomy

Whipple, 1935: successful two-stage en bloc resections of the head of the pancreas and the duodenum.

Trimble, 1941:The first one-stage pancreaticoduodenectomy

Infrequently performed until the 1980s despite technical advances because of the formidable operative morbidity, mortality.

Pancreaticoduodenectomy Complications

J Am Coll Surg 2007;204:356–364

Incidence : PPH

Arch Surg. 1992;127:945-950

Post PancreaticoduodenectomyHaemorrhage

Definitions

Early haemorrhageBleeding occurring in the first 24 h

Late haemorrhage Bleeding occurring after 24 h

Sentinel bleeding Intermittent minor haemorrhage, which implies a

fall in Hb of < 1.5 points and does not require treatment, does not destabilize the patient, but usually precedes a major haemorrhage.

Blood in the NG tube or hematemesis/melena or blood in abdominal drains

Clinical grading of bleeding severity (ISGPS classification)

Based on three parameters: Time of onset

late >24 h early <24 h

Location Intraluminal Extraluminal

Severity Mild - a drop in Hb of < 03 points with significant

clinical manifestations [tachycardia, hypotension, oliguria, shock, transfusion of > 03 units of packed red blood cells]

Severe - requiring invasive treatment [surgery or interventional radiology]

Clinical grading of bleeding severity (ISGPS classification)

Defining three grades: A, B, and C . Grade A - bleeding stops early, the patient is

clinically stable and responds to conservative medical treatment

Grade B - presents early or late, rarely threatens the patient’s life, and its treatment ranges from the conservative to laparotomy

Grade C - occurs late, is severely life-threatening, and requires aggressive treatment (laparotomy or angiography).

PPH :Types

Early PPH Technical failure of appropriate hemostasis at

anastomotic sites, e.g., suture lines and resection areaAn underlying perioperative coagulopathy

Delayed PPHUlceration of gastroenteral anastomosis (marginal

ulcer)Leakage of venous anastomosis after portal vein

resection Erosion of peripancreatic vesselsPseudoaneurysm formation - Stepwise erosion of the

celiac trunk and the SMA that may subsequently rupture.

Incidence : PPH3.1% Late PPH –

Rajarathinam et al. Post pancreaticoduodenectomy haemorrhage: outcome prediction based on new ISGPS Clinical severity grading. HPB 2008;10(5):363-70

10.4% Late PPH- Sanjay et al. Late post pancreatectomy haemorrhage. Risk factors and

modern management. JOP. 2010;5;11(3):220-225.

8.4% Eckardt et al. Management and outcomes of haemorrhage after

pancreatogastrostomy versus pancreatojejunostomy. Br J Surg 2011;98:1599-1607.

3.3% Systematic Review of Delayed Postoperative Hemorrhage after Pancreatic

Resection. J Gastrointest Surg (2011) 15:1055–1062 {n=248/7400}

Table 2. Postoperative results after pancreaticoduodenectomy in 113 patients.

Results No. of cases

Overall mortality 6 (5.3%)

Overall morbidity a:- Minor (Grades 1 and 2)- Major (Grades 3 and 4)

65 (57.5%)45 (39.8%)20 (17.7%)

Postoperative pancreatic fistula:- Grade A- Grade B- Grade C

37 (32.7%)11 (9.7%)24 (21.2%)2 (1.8%)

PPH onset:- Early:    Grade A    Grade B- Late:    Grade B    Grade C

31 (27.4%)6 (5.3%)2 (1.8%)4 (3.5%)

25 (22.1%)19 (16.8%)6 (5.3%)

Overall re-operation 6 (5.3%)

Re-operation for PPH:- Early- Late

4/31 (12.9%)2/6 (33.3%)2/25 (8.0%)

PPH Incidence

JOP. J Pancreas 2012 Mar 10; 13(2):193-198

Factors - Late PPH

The exact mechanism of hemorrhage is unclear.The presence of local sepsis and association with a

pancreatic fistula J Am Coll Surg 2004;199:186-191. Am J Surg 2007;193:454-459.

Brodsky and Turnbull - 75% of their patients had an associated pancreatic leak.

Yekebas et al - pancreatic fistula was significantly associated with PPH.

Risk factors: Late PPH

Late Postpancreatectomy Hemorrhage After Pancreaticoduodenectomy: Is It Possible to Recognize Risk Factors? JOP. J Pancreas 2012 Mar 10; 13(2):193-198.

113 Patients, Prospective study, 31Patients (27.4%) PPH

Analysed - Sex, age, comorbidities, ASA score, Type and extension of resection, texture of the pancreatic stump, Duct dilatation, treatment of the pancreatic stump and benign/Malignant

The only factor significantly related to late post-pancreatectomy hemorrhage was Postoperative pancreatic fistula (P<0.001). The severity of postoperative pancreatic fistula (P<0.001) and pancreatic anastomosis (P=0.049) independently increased the risk of late hemorrhage.

Bleeding Source & SiteSource of Bleeding:

The eroded or ruptured visceral arteries - 66% The pancreaticstump - 12% The entero-jejunostomy - 06% Unknown site - 10%

Site of Bleeding Abdominal bleeding - 58% GI bleeding - 35% Both abdominal and GI bleeding - 07% Sentinel bleeding - 41%

Systematic Review of Delayed Postoperative Hemorrhage after Pancreatic Resection. J Gastrointest Surg (2011) 15:1055–1062 {n=248/7400}

Bleeding Source

GDA 50%, CHA 21%J Gastrointest Surg (2011) 15:1055–1062

Mechanism of BleedingExtensive skeletonization of the CA and the SMA during

lymphadenectomy or resection of the pancreas may injure the vessel wall. Thermal injuries by using electrocautery Damages to the vascular outer layer during dissection.

Postoperative leak of the PJ or HJ may induce digestion of vascular structures by the erosive pancreatic or

biliary juice.Abscess formation can also erode the vessel wall or a vascular

anastomosis, e.g., after portal vein resection.Local tissue destruction may disrupt ligatures and sutures, typically

at the stump of the gastroduodenal artery.Local vessel wall necrosis –

mechanical pressure of a drain lying on a vessel ascending infection along the drain.

Diagnosis

EndoscopyGastrointestinal bleeding

Angiography ~ 90%CT Scan

Collection/AbscessPancreatic fistula

Re-laparotomy

Management

Pancreatic leak and intra-abdominal sepsis - independent risk factors of subsequent massive bleedingMainstay of delayed PPH preventionPrompt recognition and management of Pancreatic Fistula/ Leak

In case of conservatively treated pancreatic fistula, strict surveillance including a weekly CT angiography to detect the development of a pseudonaneurysm. Median Onset of delayed PPH - 13 to 27 days Post Op.

Management

The traditional treatment - surgery.Surgical access to the bleeding vessel is always difficult

the overlying pancreaticoenteric and bilioenteric anastomosis the presence of postsurgical adhesionsthe eroded bleeding vessel is also difficult to repair due to

peripancreatic inflammation and vessel wall friability.Interventional radiologial hemostasis (e.g., coiling or

stenting)preferred option in hemodynamically “Stabilized” patients.

Surgery: Indication

Acute life-threatening hemodynamic deterioration with decrease of Hb >3 g/dL or evident bleeding drained percutaneously or via the nasogastric tube

Critical hemodynamic instability with continuing requirement of packed red blood cells exceeding 6 units per 12 hours without evidence for the bleeding source by angiography/endoscopy.

In case of life-threatening situations, bedside decisions without measurement of Hb should be taken.

Management

Angiography vs Re-laparotomySuccess: 80% 76%Mortality: 22% 47% “Blind” coiling of the GDA could also provide bleeding control

after a negative angiography. Some prefer surgery as first-line therapy

Complications such as pancreatic leak and intraabdominal abscess can be treated.

Patients with pancreatic leaks can be treated conservatively if no local or systemic inflammatory response occurs.

Intraabdominal abscess can be treated by a CT-guided percutaneous drainage.

Complication of Stent/ Coiling

Complete occlusion of CHA & HA by angiographic embolization liver necrosis, intra-hepatic abscess biliary ischemia hepatic failure

However, anatomical reasons, such as kinking, and anatomical variations may impede successful stent placement.

Bleeding from the superior mesenteric artery (SMA) the potential risk of intestinal infarction subsequently to coil embolization.

To avoid these severe complications the use of covered stent was described for the treatment of bleeding of

hepatic arteries and SMA. (J Vasc Interv Radiol 1998;9:779–82).

Management Algorithm: Early PPH(Ann Surg 2007;246: 269–280)

Management Algorithm: Delayed PPH(Ann Surg 2007;246: 269–280)

Conclusion

Delayed postoperative bleeding after a pancreatic resection is a rare but highly lethal complication.

The prompt recognition and treatment of risk factors such as pancreatic leakage and intra-abdominal abscess is essential to prevent its deleterious outcome.

Sentinel bleeding occurring after a pancreatic surgery needs to be thoroughly investigated for a pseudoaneurysm formation.

If detected, interventional angiography provides optimal management by avoiding collateral damage after major revisional surgery.

Surgery - therapeutic option if no interventional radiology is available, or patients cannot be resuscitated for an interventional treatment

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