Kamada Yasuyuki, Hori Tomohide, Yamamoto Hidekazu, Harada Hideki, Yamamoto Michihiro, Yamada Masahiro, Yazawa Takefumi, Sasaki Ben, Tani Masaki, Sato Asahi, Katsura Hikotaro, Tani Ryotaro, Aoyama Ryuhei, Sasaki Yudai, Okada Masaharu, Zaima Masazumi
Department of Surgery, Shiga General Hospital, Moriyama 524-8524, Shiga, Japan.
Department of Cardiovascular Medicine, Shiga General Hospital, Moriyama 524-8524, Shiga, Japan.
World J Hepatol. 2021 Apr 27;13(4):483-503. doi: 10.4254/wjh.v13.i4.483.
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.
To present our data here along with a discussion of therapeutic strategies for fatal arterial hemorrhage after PD.
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.
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.
Transcatheter placement of a covered stent may be useful for simultaneous accomplishment of complete hemostasis and HA flow preservation.
尽管胰十二指肠切除术（PD）后动脉出血并不常见，但却是致命的。动脉出血是由假性动脉瘤破裂引起的，胃十二指肠动脉残端和肝动脉（HA）是常见的责任血管。诊断程序和成像方式存在一定困难。PD后同时实现完全止血和保留HA血流很困难。尽管通过血管内治疗（EVT）或手术可能实现完全止血，但可能会发生肝缺血导致的肝梗死和/或胆缺血导致的肝脓肿。我们在此讨论PD后致命性动脉出血的治疗选择。
在此展示我们的数据，并讨论PD后致命性动脉出血的治疗策略。
我们回顾性研究了16例PD后发生动脉出血的患者。评估了患者的临床特征、诊断程序、实际治疗方法[经导管动脉栓塞术（TAE）、覆膜支架置入术或手术]、临床病程和结局。
PD后动脉出血的发生率为5.5%。12例患者观察到胰漏。出血发生的中位时间为PD后18天。5例患者观察到哨兵出血。初始EVT程序为7例患者行覆膜支架置入术，6例患者行TAE，2例患者行联合治疗。初始EVT的技术成功率为75.0%，4例患者进行了额外的EVT。8例患者采用了包括动门脉分流术在内的手术方法。TAE后2例患者观察到肝梗死。即使EVT成功，仍有2例患者预后不良。这4例临床病程和结局较差的患者在EVT前临床状况不佳。14例患者成功治愈。
经导管置入覆膜支架可能有助于同时实现完全止血和保留HA血流。
