Advertisement

Beyond successful hemostasis: CT findings and organ failure predict postoperative death in patients suffering from post-pancreatoduodenectomy hemorrhage

  • Author Footnotes
    ∗ Equally contributed as first authors.
    Jie Yang
    Footnotes
    ∗ Equally contributed as first authors.
    Affiliations
    Department of Pancreatic Surgery, West China Hospital, Sichuan University, No. 37 Guoxue Alley, Wuhou District, Chengdu 610041, Sichuan Province, China
    Search for articles by this author
  • Author Footnotes
    ∗ Equally contributed as first authors.
    Yonghua Chen
    Footnotes
    ∗ Equally contributed as first authors.
    Affiliations
    Department of Pancreatic Surgery, West China Hospital, Sichuan University, No. 37 Guoxue Alley, Wuhou District, Chengdu 610041, Sichuan Province, China
    Search for articles by this author
  • Xubao Liu
    Affiliations
    Department of Pancreatic Surgery, West China Hospital, Sichuan University, No. 37 Guoxue Alley, Wuhou District, Chengdu 610041, Sichuan Province, China
    Search for articles by this author
  • Zhenjiang Zheng
    Affiliations
    Department of Pancreatic Surgery, West China Hospital, Sichuan University, No. 37 Guoxue Alley, Wuhou District, Chengdu 610041, Sichuan Province, China
    Search for articles by this author
  • Xing Wang
    Affiliations
    Department of Pancreatic Surgery, West China Hospital, Sichuan University, No. 37 Guoxue Alley, Wuhou District, Chengdu 610041, Sichuan Province, China
    Search for articles by this author
  • Yichen Li
    Affiliations
    Department of Pancreatic Surgery, West China Hospital, Sichuan University, No. 37 Guoxue Alley, Wuhou District, Chengdu 610041, Sichuan Province, China
    Search for articles by this author
  • Chunlu Tan
    Correspondence
    Correspondence: Chunlu Tan, Department of Pancreatic Surgery, West China Hospital, Sichuan University, No.37 Guoxue Alley, Wuhou District, Chengdu 610041, Sichuan Province, China.
    Affiliations
    Department of Pancreatic Surgery, West China Hospital, Sichuan University, No. 37 Guoxue Alley, Wuhou District, Chengdu 610041, Sichuan Province, China
    Search for articles by this author
  • Author Footnotes
    ∗ Equally contributed as first authors.
Published:November 03, 2022DOI:https://doi.org/10.1016/j.hpb.2022.11.004

      Abstract

      Background

      To predict postoperative death even after successful hemostasis in patients with post pancreatoduodenectomy pancreatic fistula-associated hemorrhage (PPFH).

      Methods

      Patients who underwent pancreatoduodenectomy (PD) between September 2011 and August 2020 were identified. PPFH patients were enrolled in this retrospective case–control study and divided into the Cured and Death groups. Perioperative variables were analyzed, especially the characteristics of PPFH and CT image findings.

      Results

      Among the 2732 consecutive pancreaticoduodenectomies, 63 patients (2.3%) were confirmed to have PPFH. The mortality rate of patients following PPFH was 50.8% (32/63). After univariate and multivariate analysis, organ failure 24 h before initial hemorrhage (P = 0.039, OR = 11.53, 95% CI: 1.14–117.00), CT imaging findings of the operative area bubble sign (P = 0.021, OR = 5.15, 95% CI: 1.28–20.79) and PJ dehiscence (P = 0.016, OR = 8.95, 95% CI: 1.50–53.38) were remained as significant predictive factors of postoperative death for PPFH patients.

      Conclusions

      Patients following PPFH showed a high mortality rate. Organ failure and CT evidence of pancreaticojejunostomy (PJ) dehiscence and operative area bubble signs before initial hemorrhage may allow early prediction of postoperative death in PPFH patients.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to HPB
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Rumstadt B.
        • Schwab M.
        • Korth P.
        • Samman M.
        • Trede M.
        Hemorrhage after pancreatoduodenectomy.
        Ann Surg. 1998; 227: 236-241https://doi.org/10.1097/00000658-199802000-00013
        • Tien Y.W.
        • Lee P.H.
        • Yang C.Y.
        • Ho M.C.
        • Chiu Y.F.
        Risk factors of massive bleeding related to pancreatic leak after pancreaticoduodenectomy.
        J Am Coll Surg. 2005; 201: 554-559https://doi.org/10.1016/j.jamcollsurg.2005.05.007
        • Koukoutsis I.
        • Bellagamba R.
        • Morris-Stiff G.
        • Wickremesekera S.
        • Coldham C.
        • Wigmore S.J.
        • et al.
        Haemorrhage following pancreaticoduodenectomy: risk factors and the importance of sentinel bleed.
        Dig Surg. 2006; 23: 224-228https://doi.org/10.1159/000094754
        • Turrini O.
        • Moutardier V.
        • Guiramand J.
        • Lelong B.
        • Bories E.
        • Sannini A.
        • et al.
        Hemorrhage after duodenopancreatectomy: impact of neoadjuvant radiochemotherapy and experience with sentinel bleeding.
        World J Surg. 2005; 29: 212-216https://doi.org/10.1007/s00268-004-7557-3
        • Liang X.
        • Shi L.G.
        • Hao J.
        • Liu A.A.
        • Chen D.L.
        • Hu X.G.
        • et al.
        Risk factors and managements of hemorrhage associated with pancreatic fistula after pancreaticoduodenectomy.
        Hepatobiliary Pancreat Dis Int. 2017; 16: 537-544https://doi.org/10.1016/s1499-3872(17)60061-4
        • Smits F.J.
        • Verweij M.E.
        • Daamen L.A.
        • van Werkhoven C.H.
        • Goense L.
        • Besselink M.G.
        • et al.
        Impact of complications after pancreatoduodenectomy on mortality, organ failure, hospital stay, and readmission: analysis of a nationwide audit.
        Ann Surg. 2022; 275: e222-e228https://doi.org/10.1097/sla.0000000000003835
        • Wente M.N.
        • Veit J.A.
        • Bassi C.
        • Dervenis C.
        • Fingerhut A.
        • Gouma D.J.
        • et al.
        Postpancreatectomy hemorrhage (PPH): an international study group of pancreatic surgery (ISGPS) definition.
        Surgery. 2007; 142: 20-25https://doi.org/10.1016/j.surg.2007.02.001
        • Schäfer M.
        • Heinrich S.
        • Pfammatter T.
        • Clavien P.A.
        Management of delayed major visceral arterial bleeding after pancreatic surgery.
        HPB. 2011; 13: 132-138https://doi.org/10.1111/j.1477-2574.2010.00260.x
        • Balachandran P.
        • Sikora S.S.
        • Raghavendra Rao R.V.
        • Kumar A.
        • Saxena R.
        • Kapoor V.K.
        Haemorrhagic complications of pancreaticoduodenectomy.
        ANZ J Surg. 2004; 74: 945-950https://doi.org/10.1111/j.1445-1433.2004.03212.x
        • Choi S.H.
        • Moon H.J.
        • Heo J.S.
        • Joh J.W.
        • Kim Y.I.
        Delayed hemorrhage after pancreaticoduodenectomy.
        J Am Coll Surg. 2004; 199: 186-191https://doi.org/10.1016/j.jamcollsurg.2004.04.005
        • Palumbo D.
        • Tamburrino D.
        • Partelli S.
        • Gusmini S.
        • Guazzarotti G.
        • Cao R.
        • et al.
        Before sentinel bleeding: early prediction of postpancreatectomy hemorrhage (PPH) with a CT-based scoring system.
        Eur Radiol. 2021; https://doi.org/10.1007/s00330-021-07788-y
        • Uggeri F.
        • Nespoli L.
        • Sandini M.
        • Andreano A.
        • Degrate L.
        • Romano F.
        • et al.
        Analysis of risk factors for hemorrhage and related outcome after pancreatoduodenectomy in an intermediate-volume center.
        Updates Surg. 2019; 71: 659-667https://doi.org/10.1007/s13304-019-00673-w
        • Yekebas E.F.
        • Wolfram L.
        • Cataldegirmen G.
        • Habermann C.R.
        • Bogoevski D.
        • Koenig A.M.
        • et al.
        Postpancreatectomy hemorrhage: diagnosis and treatment: an analysis in 1669 consecutive pancreatic resections.
        Ann Surg. 2007; 246: 269-280https://doi.org/10.1097/01.sla.0000262953.77735.db
        • Khalsa B.S.
        • Imagawa D.K.
        • Chen J.I.
        • Dermirjian A.N.
        • Yim D.B.
        • Findeiss L.K.
        Evolution in the treatment of delayed postpancreatectomy hemorrhage: surgery to interventional radiology.
        Pancreas. 2015; 44: 953-958https://doi.org/10.1097/mpa.0000000000000347
        • Wolk S.
        • Grützmann R.
        • Rahbari N.N.
        • Hoffmann R.T.
        • Plodeck V.
        • Weitz J.
        • et al.
        Management of clinically relevant postpancreatectomy hemorrhage (PPH) over two decades - a comparative study of 1 450 consecutive patients undergoing pancreatic resection.
        Pancreatology. 2017; 17: 943-950https://doi.org/10.1016/j.pan.2017.10.006
        • Tien Y.W.
        • Wu Y.M.
        • Liu K.L.
        • Ho C.M.
        • Lee P.H.
        Angiography is indicated for every sentinel bleed after pancreaticoduodenectomy.
        Ann Surg Oncol. 2008; 15: 1855-1861https://doi.org/10.1245/s10434-008-9894-1
        • Floortje van Oosten A.
        • Smits F.J.
        • van den Heuvel D.A.F.
        • van Santvoort H.C.
        • Molenaar I.Q.
        Diagnosis and management of postpancreatectomy hemorrhage: a systematic review and meta-analysis.
        HPB. 2019; 21: 953-961https://doi.org/10.1016/j.hpb.2019.02.011
        • Gaudon C.
        • Soussan J.
        • Louis G.
        • Moutardier V.
        • Gregoire E.
        • Vidal V.
        Late postpancreatectomy hemorrhage: predictive factors of morbidity and mortality after percutaneous endovascular treatment.
        Diagn Interv Imaging. 2016; 97: 1071-1077https://doi.org/10.1016/j.diii.2016.08.003
        • Wolk S.
        • Radosa C.G.
        • Distler M.
        • Held H.C.
        • Kühn J.P.
        • Weitz J.
        • et al.
        Risk factors for in-hospital mortality after transarterial intervention after postpancreatectomy hemorrhage.
        Cardiovasc Intervent Radiol. 2020; 43: 1342-1352https://doi.org/10.1007/s00270-020-02509-2
        • Wu X.
        • Chen G.
        • Wu W.
        • Zhang T.
        • Liao Q.
        • Dai M.
        • et al.
        Management of late hemorrhage after pancreatic surgery: treatment strategy and prognosis.
        J Int Med Res. 2020; 48300060520929127https://doi.org/10.1177/0300060520929127
        • Bassi C.
        • Marchegiani G.
        • Dervenis C.
        • Sarr M.
        • Abu Hilal M.
        • Adham M.
        • et al.
        The 2016 update of the International Study Group (ISGPS) definition and grading of postoperative pancreatic fistula: 11 Years after.
        Surgery. 2017; 161: 584-591https://doi.org/10.1016/j.surg.2016.11.014
        • Koch M.
        • Garden O.J.
        • Padbury R.
        • Rahbari N.N.
        • Adam R.
        • Capussotti L.
        • et al.
        Bile leakage after hepatobiliary and pancreatic surgery: a definition and grading of severity by the International Study Group of Liver Surgery.
        Surgery. 2011; 149: 680-688https://doi.org/10.1016/j.surg.2010.12.002
        • Singer M.
        • Deutschman C.S.
        • Seymour C.W.
        • Shankar-Hari M.
        • Annane D.
        • Bauer M.
        • et al.
        The third international consensus definitions for sepsis and septic shock (Sepsis-3).
        JAMA. 2016; 315: 801-810https://doi.org/10.1001/jama.2016.0287
        • Smits F.J.
        • Henry A.C.
        • Besselink M.G.
        • Busch O.R.
        • van Eijck C.H.
        • Arntz M.
        • et al.
        Algorithm-based care versus usual care for the early recognition and management of complications after pancreatic resection in The Netherlands: an open-label, nationwide, stepped-wedge cluster-randomised trial.
        Lancet. 2022; 399: 1867-1875https://doi.org/10.1016/s0140-6736(22)00182-9
        • Smits F.J.
        • van Santvoort H.C.
        • Besselink M.G.
        • Batenburg M.C.T.
        • Slooff R.A.E.
        • Boerma D.
        • et al.
        Management of severe pancreatic fistula after pancreatoduodenectomy.
        JAMA Surg. 2017; 152: 540-548https://doi.org/10.1001/jamasurg.2016.5708
        • Loos M.
        • Strobel O.
        • Legominski M.
        • Dietrich M.
        • Hinz U.
        • Brenner T.
        • et al.
        Postoperative pancreatic fistula: microbial growth determines outcome.
        Surgery. 2018; 164: 1185-1190https://doi.org/10.1016/j.surg.2018.07.024
        • Demir E.
        • Abdelhai K.
        • Demir I.E.
        • Jäger C.
        • Scheufele F.
        • Schorn S.
        • et al.
        Association of bacteria in pancreatic fistula fluid with complications after pancreatic surgery.
        BJS Open. 2020; 4: 432-437https://doi.org/10.1002/bjs5.50272
        • McMillan M.T.
        • Vollmer Jr., C.M.
        • Asbun H.J.
        • Ball C.G.
        • Bassi C.
        • Beane J.D.
        • et al.
        The characterization and prediction of ISGPF grade C fistulas following pancreatoduodenectomy.
        J Gastrointest Surg. 2016; 20: 262-276https://doi.org/10.1007/s11605-015-2884-2
        • Yang J.
        • Li Y.C.
        • Liu X.B.
        • Tan C.L.
        Infection and image findings to predict delayed hemorrhage in postoperative pancreatic fistula patients after pancreaticoduodenectomy.
        Asian J Surg. 2022; 45: 1130-1131https://doi.org/10.1016/j.asjsur.2022.02.045
        • Melloul E.
        • Raptis D.A.
        • Clavien P.A.
        • Lesurtel M.
        Poor level of agreement on the management of postoperative pancreatic fistula: results of an international survey.
        HPB. 2013; 15: 307-314https://doi.org/10.1111/j.1477-2574.2012.00599.x
        • van Berge Henegouwen M.I.
        • De Wit L.T.
        • Van Gulik T.M.
        • Obertop H.
        • Gouma D.J.
        Incidence, risk factors, and treatment of pancreatic leakage after pancreaticoduodenectomy: drainage versus resection of the pancreatic remnant.
        J Am Coll Surg. 1997; 185: 18-24https://doi.org/10.1016/s1072-7515(97)00007-0
        • Bu X.
        • Xu J.
        • Dai X.
        A novel technique for the management of pancreaticojejunal anastomosis dehiscence following pancreaticoduodenectomy.
        Dig Surg. 2010; 27: 265-271https://doi.org/10.1159/000279811
        • Kent T.S.
        • Callery M.P.
        • Vollmer Jr., C.M.
        The bridge stent technique for salvage of pancreaticojejunal anastomotic dehiscence.
        HPB. 2010; 12: 577-582https://doi.org/10.1111/j.1477-2574.2010.00227.x
        • Paye F.
        • Lupinacci R.M.
        • Kraemer A.
        • Lescot T.
        • Chafaï N.
        • Tiret E.
        • et al.
        Surgical treatment of severe pancreatic fistula after pancreaticoduodenectomy by wirsungostomy and repeat pancreatico-jejunal anastomosis.
        Am J Surg. 2013; 206: 194-201https://doi.org/10.1016/j.amjsurg.2012.10.039
        • Wroński M.
        • Cebulski W.
        • Witkowski B.
        • Guzel T.
        • Karkocha D.
        • Lech G.
        • et al.
        Surgical management of the grade C pancreatic fistula after pancreatoduodenectomy.
        HPB. 2019; 21: 1166-1174https://doi.org/10.1016/j.hpb.2019.01.006
        • Groen J.V.
        • Smits F.J.
        • Koole D.
        • Besselink M.G.
        • Busch O.R.
        • den Dulk M.
        • et al.
        Completion pancreatectomy or a pancreas-preserving procedure during relaparotomy for pancreatic fistula after pancreatoduodenectomy: a multicentre cohort study and meta-analysis.
        Br J Surg. 2021; 108: 1371-1379https://doi.org/10.1093/bjs/znab273
        • Chen Y.
        • Tan C.
        • Zhang H.
        • Mai G.
        • Ke N.
        • Liu X.
        Novel entirely continuous running suture of two-layer pancreaticojejunostomy using only one polypropylene monofilament suture.
        J Am Coll Surg. 2013; 216: e17-e21https://doi.org/10.1016/j.jamcollsurg.2012.10.009