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Angiography is Indicated for Every Sentinel Bleed after Pancreaticoduodenectomy

  • Hepatic and Pancreatic Tumors
  • Published:
Annals of Surgical Oncology Aims and scope Submit manuscript

Abstract

Background

Delayed massive bleeding is one of the leading causes of mortality after pancreaticoduodenectomy (PD) and is often preceded by sentinel bleed. Immediate and accurate diagnosis of sentinel bleed is essential to save patients from a delayed massive hemorrhage. Angiography is probably the procedure of choice for patients with sentinel bleed after PD, as it will localize the bleeding point and provide interventional embolization. The purpose of this study is to test the efficiency of angiography as the initial management for patients with sentinel bleed after pancreaticoduodenectomy.

Methods

The study group consisted of 283 patients who underwent PD from July 2002 to June 2007. Angiography and arterial embolization were performed for every sentinel bleed and detected pseudoaneurysm. Patients (n = 311) from a previous study (July 1996–June 2002) were used as a historical control group.

Results

Sentinel bleed was detected in 20 patients in study group. Of these, angiography-detected pseudoaneurysm was evident in seven (35%); all were successfully embolized. Delayed massive hemorrhage occurred in three of 13 patients with sentinel bleed but negative angiography. All three were operated on; one died of uncontrolled bleeding. The number of hemodynamically unstable patients before transfusion, units of transfused packed cells, and bleeding related mortalities were significantly less in study group than the control group.

Conclusions

Institution of angiography for every detected sentinel bleed after PD enabled us to embolize seven pseudoaneurysms before massive hemorrhage. Most importantly, bleeding-related mortality was significantly less than in the absence of angiography.

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References

  1. Sakorafas GH, Farnell MB, Nagorney DM, et al. Pancreatoduodenectomy for chronic pancreatitis: long-term results in 105 patients. Arch Surg 2000; 135:517–23

    Article  PubMed  CAS  Google Scholar 

  2. Takano S, Ito Y, Watanabe Y, et al. Pancreaticojejunostomy versus pancreaticogastrostomy in reconstruction following pancreaticoduodenectomy. Br J Surg 2000; 87:423–7.

    Article  PubMed  CAS  Google Scholar 

  3. Buchler MW, Friess H, Wagner M, et al. Pancreatic fistula after pancreatic head resection. Br J Surg 2000; 87:883–9

    Article  PubMed  CAS  Google Scholar 

  4. Yeo CJ, Cameron JL, Lillemoe KD, et al. Does prophylactic octreotide decrease the rates of pancreatic fistula and other complications after pancreaticoduodenectomy? Results of a prospective randomized placebo-controlled trial. Ann Surg 2000; 232:419–29

    Article  PubMed  CAS  Google Scholar 

  5. Gouma DJ, van Geenen RC, van Gulik TM, et al. Rates of complications and death after pancraeticoduodenectomy: risk factors and the impact of hospital volume. Ann Surg 2000; 232:786–95

    Article  PubMed  CAS  Google Scholar 

  6. Miedema BW, Sarr MG, van Heerden JA, et al. Complications following pancreaticoduodenectomy. Current management. Arch Surg 1992; 127:945–9

    PubMed  CAS  Google Scholar 

  7. Yeo CJ, Cameron JL, Sohn TA, et al. Six hundred fifty consecutive pancreaticoduodenectomies in the 1990s: pathology, complications, and outcomes. Ann Surg 1997; 226:248–57

    Article  PubMed  CAS  Google Scholar 

  8. Cameron JL, Pitt HA, Yeo CJ, et al. One hundred and forty-five consecutive pancreaticoduodenectomies without mortality. Ann Surg 1993; 217:430–5

    Article  PubMed  CAS  Google Scholar 

  9. Sugimoto H, Kaneko T, Ishiguchi T, et al. Delayed rupture of a pseudoaneurysm following pancreatoduodenectomy—report of a case. Surg Today 2001; 31:932–5

    Article  PubMed  CAS  Google Scholar 

  10. Papadimitriou J, Vassiliou J, Papadimitriou L, et al. Delayed haemorrhage after pancreatoduodenectomy. Int Surg 2000; 85: 275

    PubMed  CAS  Google Scholar 

  11. Yoshida T, Matsumoto T, Morii Y, et al. Delayed massive intraperitoneal hemorrhage after pancreatoduodenectomy. Int Surg 1998; 83:131–5

    PubMed  CAS  Google Scholar 

  12. Otah E, Cushin BJ, Rozenblit GN, et al. Visceral artery pseudoaneurysms following pancreatoduodenectomy. Arch Surg 2002; 137:55–9

    Article  PubMed  Google Scholar 

  13. Rumstadt B, Schwab M, Korth P, et al. Hemorrhage after pancraeticoduodenectomy. Ann Surg 1998; 227:236–41

    Article  PubMed  CAS  Google Scholar 

  14. Choi SH, Moon HJ, Heo JS, et al. Delayed hemorrhage after pancreaticoduodenectomy. J Am Coll Surg 2004;199:186–91

    Article  PubMed  Google Scholar 

  15. 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

    Article  PubMed  Google Scholar 

  16. Tien YW, Lee PH, Yang CY, et al. Risk factors of massive bleeding related to pancreatic leak after pancreaticoduodenectomy. J Am Coll Surg 2005;201:554–9

    Article  PubMed  Google Scholar 

  17. Bassi C, Dervenis C, Butturini G, et al. Postoperative pancreatic fistula: An international study group (ISGPF) definition. Surgery 2005; 138:8–13

    Article  PubMed  Google Scholar 

  18. Shankar S, Russell RCG. Hemorrhage in pancreatic disease. Br J Surg 1989; 76:863–6

    Article  PubMed  CAS  Google Scholar 

  19. Brodsky JT, Turnbull AD. Arterial hemorrhage after pancreaticoduodenectomy: the “Sentinel bleed”. Arch Surg 1991: 126:1037–40

    PubMed  CAS  Google Scholar 

  20. Sato N, Yamaguchi K, Shimizu S, et al. Coil embolization of bleeding visceral pseudoaneurysms following pancreatectomy. The importance of early angiography. Arch Surg 1998; 133:1099–102

    Article  PubMed  CAS  Google Scholar 

  21. de Castro SMM, Kuhlmann KFD, Busch ORC, et al. Delayed massive hemorrhage after pancreatic and biliary surgery. Embolization or surgery? Ann Surg 2005; 241:85–91

    PubMed  Google Scholar 

  22. Yoshida T, Ninomiya S, Matsumata T. Management of bleeding pseudoaneurysms after pancreatoduodenectomy. Arch Surg 2003; 138:458

    Article  PubMed  Google Scholar 

  23. Blanc T, Cortes A, Goere D, et al. Hemorrhage after pancreaticoduodenectomy: when is surgery still indicated? Am J Surg 2007; 194:3–9

    Article  PubMed  Google Scholar 

  24. Zeally IA, Tait IS, Polignano FM. Delayed massive hemorrhage after pancreatic and biliary surgery: embolization or surgery? Ann Surg 2006; 243:138–9

    Article  Google Scholar 

  25. Mansueto G, D’Onofrio M, Iacono C, et al. Gastroduodenal artery stump haemorrhage following pylorus-sparing Whipple procedure: treatment with covered stents. Dig Surg 2002; 19:237–40

    Article  PubMed  Google Scholar 

  26. Venturini M, Angeli E, Salvioni M, et al. Hemorrhage from a right hepatic artery pseudoaneurysm: endovascular treatment with coronary stent-graft. J Endovasc Ther 2002; 9:221–4

    Article  PubMed  Google Scholar 

  27. Rami P, Williams D, Forauer A, et al. Stent-graft treatment of patients with acute bleeding from hepatic artery branches. Cardiovasc Intervent Radiol 2005;28:153–8

    Article  PubMed  Google Scholar 

  28. de Castro S, Busch O, van Delden O, et al. Delayed massive hemorrhage after pancreatic and biliary surgery: embolization or surgery? Ann Surg 2006; 243:139

    Article  Google Scholar 

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Authors and Affiliations

  1. Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan, Republic of China

    Yu-Wen Tien MD, PhD, Yao-Ming Wu MD, Cheng-Maw Ho MD & Po-Huang Lee MD, PhD

  2. Department of Radiology, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan, Republic of China

    Kao-Lang Liu MD

Authors
  1. Yu-Wen Tien MD, PhD
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  2. Yao-Ming Wu MD
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  3. Kao-Lang Liu MD
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  4. Cheng-Maw Ho MD
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  5. Po-Huang Lee MD, PhD
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Correspondence to Yu-Wen Tien MD, PhD.

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Tien, YW., Wu, YM., Liu, KL. et al. Angiography is Indicated for Every Sentinel Bleed after Pancreaticoduodenectomy. Ann Surg Oncol 15, 1855–1861 (2008). https://doi.org/10.1245/s10434-008-9894-1

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  • DOI: https://doi.org/10.1245/s10434-008-9894-1

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