Retrospective Study
Copyright ©The Author(s) 2021. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Hepatol. Apr 27, 2021; 13(4): 483-503
Published online Apr 27, 2021. doi: 10.4254/wjh.v13.i4.483
Fatal arterial hemorrhage after pancreaticoduodenectomy: How do we simultaneously accomplish complete hemostasis and hepatic arterial flow?
Yasuyuki Kamada, Tomohide Hori, Hidekazu Yamamoto, Hideki Harada, Michihiro Yamamoto, Masahiro Yamada, Takefumi Yazawa, Ben Sasaki, Masaki Tani, Asahi Sato, Hikotaro Katsura, Ryotaro Tani, Ryuhei Aoyama, Yudai Sasaki, Masaharu Okada, Masazumi Zaima
Yasuyuki Kamada, Tomohide Hori, Hidekazu Yamamoto, Hideki Harada, Michihiro Yamamoto, Masahiro Yamada, Takefumi Yazawa, Ben Sasaki, Masaki Tani, Asahi Sato, Hikotaro Katsura, Ryotaro Tani, Ryuhei Aoyama, Yudai Sasaki, Masazumi Zaima, Department of Surgery, Shiga General Hospital, Moriyama 524-8524, Shiga, Japan
Masaharu Okada, Department of Cardiovascular Medicine, Shiga General Hospital, Moriyama 524-8524, Shiga, Japan
Author contributions: Kamada Y collected the data; Kamada Y and Hori T analyzed the data, reviewed the published literature and wrote the manuscript; Kamada Y and Hori T contributed equally to this work; all authors discussed therapeutic options, reviewed previous papers, and provided important opinions; Zaima M and Hori T supervised this report.
Institutional review board statement: This report was approved by the Institutional Review Board of Shiga General Hospital, Moriyama, Japan.
Informed consent statement: The patients involved in this study provided written informed consent authorizing the use and disclosure of their protected health information.
Conflict-of-interest statement: None of the authors have any financial conflicts of interest to declare.
Data sharing statement: No additional data are available.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Tomohide Hori, FACS, MD, PhD, Associate producer, Surgeon, Department of Surgery, Shiga General Hospital, 5-4-30 Moriyama, Moriyama 524-8524, Shiga, Japan. horitomo55office@yahoo.co.jp
Received: February 3, 2021
Peer-review started: February 3, 2021
First decision: March 1, 2021
Revised: March 7, 2021
Accepted: March 19, 2021
Article in press: March 19, 2021
Published online: April 27, 2021
Processing time: 71 Days and 23.7 Hours
Abstract
BACKGROUND

Although arterial hemorrhage after pancreaticoduodenectomy (PD) is not frequent, it is fatal. Arterial hemorrhage is caused by pseudoaneurysm rupture, and the gastroduodenal artery stump and hepatic artery (HA) are frequent culprit vessels. Diagnostic procedures and imaging modalities are associated with certain difficulties. Simultaneous accomplishment of complete hemostasis and HA flow preservation is difficult after PD. Although complete hemostasis may be obtained by endovascular treatment (EVT) or surgery, liver infarction caused by hepatic ischemia and/or liver abscesses caused by biliary ischemia may occur. We herein discuss therapeutic options for fatal arterial hemorrhage after PD.

AIM

To present our data here along with a discussion of therapeutic strategies for fatal arterial hemorrhage after PD.

METHODS

We retrospectively investigated 16 patients who developed arterial hemorrhage after PD. The patients’ clinical characteristics, diagnostic procedures, actual treatments [transcatheter arterial embolization (TAE), stent-graft placement, or surgery], clinical courses, and outcomes were evaluated.

RESULTS

The frequency of arterial hemorrhage after PD was 5.5%. Pancreatic leakage was observed in 12 patients. The onset of hemorrhage occurred at a median of 18 d after PD. Sentinel bleeding was observed in five patients. The initial EVT procedures were stent-graft placement in seven patients, TAE in six patients, and combined therapy in two patients. The rate of technical success of the initial EVT was 75.0%, and additional EVTs were performed in four patients. Surgical approaches including arterioportal shunting were performed in eight patients. Liver infarction was observed in two patients after TAE. Two patients showed a poor outcome even after successful EVT. These four patients with poor clinical courses and outcomes had a poor clinical condition before EVT. Fourteen patients were successfully treated.

CONCLUSION

Transcatheter placement of a covered stent may be useful for simultaneous accomplishment of complete hemostasis and HA flow preservation.

Keywords: Pancreaticoduodenectomy; Endovascular treatment; Stent-graft; Covered stent; Transcatheter arterial embolization; Arterioportal shunting

Core Tip: Arterial hemorrhage after pancreaticoduodenectomy is fatal. This hemorrhage is caused by pseudoaneurysm rupture, and the gastroduodenal artery stump and hepatic artery are frequent culprit vessels. Simultaneous accomplishment of complete hemostasis and hepatic artery flow preservation is difficult after pancreaticoduodenectomy. Although complete hemostasis may be obtained by transcatheter arterial embolization or surgery, liver infarction and/or abscesses may occur. We here evaluate our experience including actual treatments (transcatheter arterial embolization, stent-graft placement, or surgery), and discuss therapeutic strategies. Transcatheter placement of a covered stent is useful for simultaneous accomplishment of complete hemostasis and hepatic arterial flow preservation.