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Management of bleeding and leakage after pancreatic surgery

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Pancreatic surgery has advanced considerably during the past decades. Recent studies report reduced morbidity rates and virtually no mortality after resection. However, postoperative complications are still a formidable menace. In this chapter we discuss the management of postoperative bleeding and leakages which are considered the most feared complications, and discuss the advent of minimal invasive methods for management of these complications.

Patients who develop postoperative bleeding almost always present with septic complications and a sentinel bleed before onset of bleeding. These patients should undergo early diagnostic angiography followed by embolisation. If this does control the bleeding an emergency laparotomy should be performed as last resort.

Patients who develop pancreatic leakage are generally managed conservatively by means of percutaneous drainage. Aggressive surgery should be performed at the first sign of severe sepsis. The condition of the pancreatic remant found during reoperation dictates the type of surgical intervention best performed.

Section snippets

Postoperative bleeding

The incidence of postoperative bleeding after pancreatoduodenectomy varies considerably in the literature and occurs in 1.5–12% of patients.6., 9., 21., 38., 43., 50., 51., 52., 53., 54., 55., 56. The wide variation is caused by the different definitions used by various authors (Table 1).

Generally, postoperative bleeding can be divided into early and late postoperative bleeding. Bleeding within 24 hours after surgery is generally the result of a poor or nonsecured vessel or bleeding at the

Symptoms

In a recent study we found that the occurrence of a so-called sentinel bleed is a key sign before the onset of delayed bleeding. Others also reported the importance of the sentinel bleed.51., 52., 57. Patients who develop such a relatively mild sentinel bleed (ranging from 100 ml to 3 l) in particular during a septic postoperative period have a high risk of developing imminent massive bleeding and should undergo diagnostic and therapeutic intervention after this first bleeding.50., 51., 52.

Diagnostic procedures

A patient presenting with a sentinel bleed and in a stable condition should undergo CT scan with intravenous contrast (Figure 1) to look for bleeding from a false aneurysm. If a CT-scan does not yield a focus for the bleeding and in particular if the patient is unstable the next procedure should be a selective angiography (Figure 2, Figure 3). Caution should be taken interpreting the results of an angiography because negative examination does not rule out a possible bleeding site.52 The

Treatment and outcome

Management should firstly consist of stabilizing the patient by means of resuscitation and supply of blood products and diagnostic intervention. Immediately thereafter, the patient should undergo emergency selective angiography for embolisation (Figure 2, Figure 3). Although, most patients will eventually still require surgical intervention for concomitant inflammation such as pancreatic leakage and sepsis, surgery in a not severely bleeding patient is obviously less risky. Embolisation is

Pancreatic leakage

The terminology to define pancreatic leakage, pancreatic fistula or anastomotic insufficiency is confusing in the literature. Some surgeons advocate to use the term fistula while others insist on pancreatic leakage and still others use anastomotic insufficiency. All terms are interchangeable. We prefer to use ‘pancreatic leakage’ defined as a high amylase level (more than 3 times serum amylase) in the abdominal drain fluid, or pancreatic anastomotic leakage proved by radiological examination,

Risk factors for the development of pancreatic leakage

Many anastomotic techniques have been described during the past years to improve management of the pancreatic remnant and to prevent pancreatic leakage. Some studies show a lower leakage rate after pancreaticogastrostomy but these were not randomised.61., 62., 63., 64., 65., 66. A recent randomised controlled trial from the Hopkins Institute showed no benefit for pancreaticogastrostomy versus pancreaticojejunostomy with a leakage rate of 12.3 versus 11.1%, respectively.26 Furthermore, drainage

Symptoms

Most commonly, pancreatic leakage is recognised between the third and sixth postoperative day. Patients may complain of dyspnoea and markedly increased abdominal pain but can also present without specific symptoms. Patients commonly suffer from delayed gastric emptying before the onset of pancreatic leakage.58., 71. Physical examination often reveals pleural effusion with fever and an increased pulse rate. An increased production of drain fluid with high amylase content is often seen but is not

Diagnostic procedure

A chest X-ray is generally the first examination performed in patient complaining of dyspnoea. The examination usually shows basal pleural effusion in up to 75% of the patients.58., 90. Whether this effusion is a reaction of the pleural viscera due to intra-abdominal infection or amylase leakage into the chest cavity remains controversial.

Pancreatic leakage is essentially a clinical diagnosis. A CT-scan of the abdomen may reveal an oedematous pancreatic remnant or peripancreatic fluid

Treatment and outcome

There is an enormous difference in management of leakage ranging from only drainage via the already placed drains up to resection of the necrotic pancreatic remnant. In up to 80% of patients with pancreatic leakage spontaneous resolution will occur with conservative drainage, usually within 2 or 3 weeks.24 Major centres still report a leakage rate of 10–15% and a reduced reoperation rate of around 4.0%.1., 4., 11. These data suggest that improvements in perioperative care, especially the

Biliary leakage

Leakage of the hepaticojejunostomy after pancreatic surgery is a rare occurrence. The incidence rate varies from 3 to 9% in the literature and these patients seldom require invasive intervention.4., 7., 47., 83., 95. Conservative management by adequate bile drainage is instituted for patients with uncomplicated leakage. Percutaneous transhepatic cholangiography may be necessary if the patient develops cholangitis or if the leakage persists. Drainography can show extravasation of contrast into

Hospital and surgeon volume

Several studies have shown that the experience in performing pancreatic resections results in better short-term outcomes (in-hospital mortality rate) when these procedures are performed by high-volume surgeons, in high-volume hospitals, or both, even after adjusting for differences in comorbidity of the patients.12., 48., 96., 97., 98., 99.

Notwithstanding the fact that some low-volume hospitals have good outcomes and some high volume centre have a relatively poor outcome, it is clear that

Summary

Pancreatoduodenectomy is still associated with a high morbidity. Complications such as postoperative bleeding and pancreatic leakage have a wide variation in incidence in the literature due to different definitions. Postoperative bleeding after pancreatic surgery carries the highest mortality rate. If a sentinel bleeding occurs due to septic complications later, the surgeon should seriously consider the possibility of imminent bleeding from a pseudoaneurysm and perform an emergency angiography.

References (100)

  • Y. Hamanaka et al.

    Pancreatic juice output after pancreatoduodenectomy in relation to pancreatic consistency, duct size, and leakage

    Surgery

    (1996)
  • T.A. Sohn et al.

    Pancreaticoduodenectomy: role of interventional radiologists in managing patients and complications

    Journal of Gastrointestinal Surgery

    (2003)
  • M.W. Buchler et al.

    Pancreatic fistula after pancreatic head resection

    British Journal of Surgery

    (2000)
  • J.P. Neoptolemos et al.

    Low mortality following resection for pancreatic and periampullary tumours in 1026 patients: UK survey of specialist pancreatic units. UK Pancreatic Cancer Group

    British Journal of Surgery

    (1997)
  • M. Trede et al.

    Resection of pancreatic cancer—surgical achievements

    Langenbecks Archives of Surgery

    (1998)
  • C.J. Yeo et al.

    Six hundred fifty consecutive pancreaticoduodenectomies in the 1990s: pathology, complications, and outcomes

    Annals of Surgery

    (1997)
  • M.I. Berge Henegouwen et al.

    Postoperative weight gain after standard Whipple's procedure versus pylorus-preserving pancreatoduodenectomy: the influence of tumour status

    British Journal of Surgery

    (1998)
  • T.C. Bottger et al.

    Factors influencing morbidity and mortality after pancreaticoduodenectomy: critical analysis of 221 resections

    World Journal of Surgery

    (1999)
  • J.L. Cameron et al.

    One hundred and forty-five consecutive pancreaticoduodenectomies without mortality

    Annals of Surgery

    (1993)
  • M. Trede et al.

    Survival after pancreatoduodenectomy. 118 consecutive resections without an operative mortality

    Annals of Surgery

    (1990)
  • M.W. Buchler et al.

    Changes in morbidity after pancreatic resection: toward the end of completion pancreatectomy

    Archives of Surgery

    (2003)
  • J.D. Birkmeyer et al.

    Surgeon volume and operative mortality in the United States

    New England Journal of Medicine

    (2003)
  • W. Kausch

    Das Carcinom der Papilla duodeni und seine radikale Enfferung

    Beitrage Klinischen Chirurgie

    (1912)
  • A.O. Whipple et al.

    Treatment of carcinoma of the ampulla of Vater

    Annals of Surgery

    (1935)
  • L. Jones et al.

    Standard Kausch–Whipple pancreatoduodenectomy

    Digistive Surgery

    (1999)
  • L.W. Traverso et al.

    Preservation of the pylorus in pancreaticoduodenectomy a follow-up evaluation

    Annals of Surgery

    (1980)
  • C. Fernandez-del Castillo et al.

    Standards for pancreatic resection in the 1990s

    Archives of Surgery

    (1995)
  • K.M. Itani et al.

    Pylorus-preserving pancreatoduodenectomy. A clinical and physiologic appraisal

    Annals of Surgery

    (1986)
  • A.G. Patel et al.

    Pylorus-preserving Whipple resection for pancreatic cancer. Is it any better?

    Archives of Surgery

    (1995)
  • K.W. Sharp et al.

    Pancreatoduodenectomy with pyloric preservation for carcinoma of the pancreas: a cautionary note

    Surgery

    (1989)
  • J.I. Tsao et al.

    Pylorus-preserving pancreatoduodenectomy. Is it an adequate cancer operation

    Archives of Surgery

    (1994)
  • A.L. Warshaw et al.

    Delayed gastric emptying after pylorus-preserving pancreaticoduodenectomy

    Surgery, Gynecology and Obstetrics

    (1985)
  • C.J. Yeo et al.

    Erythromycin accelerates gastric emptying after pancreaticoduodenectomy. A prospective, randomized, placebo-controlled trial

    Annals of Surgery

    (1993)
  • C.J. Yeo et al.

    A prospective randomized trial of pancreaticogastrostomy versus pancreaticojejunostomy after pancreaticoduodenectomy

    Annals of Surgery

    (1995)
  • K. Tran et al.

    Occlusion of the pancreatic duct versus pancreaticojejunostomy: a prospective randomized trial

    Annals of Surgery

    (2002)
  • H. Obertop et al.

    Current views on surgical treatment of pancreatic cancer

    Digestive Surgery

    (1999)
  • C.J. Yeo et al.

    Pancreaticoduodenectomy with or without extended retroperitoneal lymphadenectomy for periampullary adenocarcinoma: comparison of morbidity and mortality and short-term outcome

    Annals of Surgery

    (1999)
  • K. Satake et al.

    Surgical curability and prognosis for standard versus extended resection for T1 carcinoma of the pancreas

    Surgery, Gynecology and Obstetrics

    (1992)
  • D. Henne-Bruns et al.

    Surgery for ductal adenocarcinoma of the pancreatic head: staging, complications, and survival after regional versus extended lymphadenectomy

    World Journal of Surgery

    (2000)
  • S. Pedrazzoli et al.

    Standard versus extended lymphadenectomy associated with pancreatoduodenectomy in the surgical treatment of adenocarcinoma of the head of the pancreas: a multicenter, prospective, randomized study. Lymphadenectomy Study Group

    Annals of Surgery

    (1998)
  • C.J. Yeo et al.

    Pancreaticoduodenectomy with or without distal gastrectomy and extended retroperitoneal lymphadenectomy for periampullary adenocarcinoma, part 2: randomized controlled trial evaluating survival, morbidity, and mortality

    Annals of Surgery

    (2002)
  • J.H. Allema et al.

    Prognostic factors for survival after pancreaticoduodenectomy for patients with carcinoma of the pancreatic head region

    Cancer

    (1995)
  • V. DiCarlo et al.

    Pancreatic cancer resection in elderly patients

    British Journal of Surgery

    (1998)
  • R.J. Geer et al.

    Prognostic indicators for survival after resection of pancreatic adenocarcinoma

    The American Journal of Surgery

    (1993)
  • L.W. Traverso et al.

    The Whipple procedure for severe complications of chronic pancreatitis

    Archives of Surgery

    (1993)
  • S.A. Barens et al.

    Pancreaticoduodenectomy for benign disease

    The American Journal of Surgery

    (1996)
  • R.F. Martin et al.

    Long-term results of pylorus-preserving pancreatoduodenectomy for chronic pancreatitis

    Archives of Surgery

    (1996)
  • G.H. Sakorafas et al.

    Pancreatoduodenectomy for chronic pancreatitis: long-term results in 105 patients

    Archives of Surgery

    (2000)
  • K.E. Bakkevold et al.

    Morbidity and mortality after radical and palliative pancreatic cancer surgery. Risk factors influencing the short-term results

    Annals of Surgery

    (1993)
  • Y. Matsumoto et al.

    Successful pancreatojejunal anastomosis for pancreatoduodenectomy

    Surgery, Gynecology and Obstetrics

    (1992)

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