Hepatopancreatobiliary Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York.
Department of General Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania.
JAMA Surg. 2024 Aug 1;159(8):891-899. doi: 10.1001/jamasurg.2024.1228.
Postpancreatectomy hemorrhage is an uncommon but highly morbid complication of pancreaticoduodenectomy. Clinical evidence often draws suspicion to the gastroduodenal artery stump, even without a clear source.
To determine the frequency of gastroduodenal artery bleeding compared to other sites and the results of mitigation strategies.
DESIGN, SETTING, AND PARTICIPANTS: This cohort study involved a retrospective analysis of data for consecutive patients who had pancreaticoduodenectomy from 2011 to 2021 at Memorial Sloan Kettering Cancer Center (MSK) and Thomas Jefferson University Hospital (TJUH).
Demographic, perioperative, and disease-related variables.
The incidence, location, treatment, and outcomes of primary (initial) and secondary (recurrent) hemorrhage requiring invasive intervention were analyzed. Imaging studies were re-reviewed by interventional radiologists to confirm sites.
Inclusion criteria were met by 3040 patients (n = 1761 MSK, n = 1279 TJUH). Patients from both institutions were similar in age (median [IQR] age at MSK, 67 [59-74] years, and at TJUH, 68 [60-75] years) and sex (at MSK, 814 female [46.5%] and 947 male [53.8%], and at TJUH, 623 [48.7%] and 623 male [51.3%]). Primary hemorrhage occurred in 90 patients (3.0%), of which the gastroduodenal artery was the source in 15 (16.7%), unidentified sites in 24 (26.7%), and non-gastroduodenal artery sites in 51 (56.7%). Secondary hemorrhage occurred in 23 patients; in 4 (17.4%), the gastroduodenal artery was the source. Of all hemorrhage events (n = 117), the gastroduodenal artery was the source in 19 (16.2%, 0.63% incidence in all pancreaticoduodenectomies). Gastroduodenal artery hemorrhage was more often associated with soft gland texture (14 [93.3%] vs 41 [62.1%]; P = .02) and later presentation (median [IQR], 21 [15-26] vs 10 days [5-18]; P = .002). Twenty-three patients underwent empirical gastroduodenal artery embolization or stent placement, 7 (30.4%) of whom subsequently experienced secondary hemorrhage. Twenty percent of all gastroduodenal artery embolizations/stents (8/40 patients), including 13% (3/13 patients) of empirical treatments, were associated with significant morbidity (7 hepatic infarction, 4 biliary stricture), with a 90-day mortality rate of 38.5% (n = 5) for patients with these complications vs 7.8% without (n = 6; P = .008). Ninety-day mortality was 12.2% (n = 11) for patients with hemorrhage (3 patients [20%] with primary gastroduodenal vs 8 [10.7%] for all others; P = .38) compared with 2% (n = 59) for patients without hemorrhage.
In this study, postpancreatectomy hemorrhage was uncommon and the spectrum was broad, with the gastroduodenal artery responsible for a minority of bleeding events. Empirical gastroduodenal artery embolization/stent without obvious sequelae of recent hemorrhage was associated with significant morbidity and rebleeding and should not be routine practice. Successful treatment of postpancreatectomy hemorrhage requires careful assessment of all potential sources, even after gastroduodenal artery mitigation.
背景：胰十二指肠切除术后出血是一种罕见但高度致命的并发症。临床证据常常怀疑胃十二指肠动脉残端，但即使没有明确的来源也是如此。
目的：确定胃十二指肠动脉出血与其他部位出血的频率以及缓解策略的结果。
设计、地点和参与者：这项队列研究回顾性分析了 2011 年至 2021 年期间在纪念斯隆凯特琳癌症中心（MSK）和托马斯杰斐逊大学医院（TJUH）接受胰十二指肠切除术的连续患者的数据。
暴露因素：人口统计学、围手术期和疾病相关变量。
主要结果和措施：分析了原发性（初始）和继发性（复发性）需要侵入性干预的出血的发生率、位置、治疗和结果。对影像学研究进行了重新审查，由介入放射科医生确认部位。
结果：符合纳入标准的患者共有 3040 名（n=1761 MSK，n=1279 TJUH）。来自两个机构的患者在年龄（MSK 中位数[IQR]年龄为 67 [59-74]岁，TJUH 为 68 [60-75]岁）和性别（MSK 为 814 名女性[46.5%]和 947 名男性[53.8%]，TJUH 为 623 名[48.7%]和 623 名男性[51.3%]）方面相似。90 名患者（3.0%）发生原发性出血，其中胃十二指肠动脉为 15 名（16.7%），未确定部位 24 名（26.7%），非胃十二指肠动脉部位 51 名（56.7%）。发生继发性出血 23 例，其中 4 例（17.4%）为胃十二指肠动脉来源。在所有出血事件（n=117）中，胃十二指肠动脉为 19 例（16.2%，所有胰十二指肠切除术中的发生率为 0.63%）。胃十二指肠动脉出血更常与软腺质地有关（14 [93.3%] vs 41 [62.1%]；P=0.02）和较晚出现（中位数[IQR]，21 [15-26] vs 10 天[5-18]；P=0.002）。23 名患者接受了胃十二指肠动脉栓塞或支架置入术，其中 7 名（30.4%）随后发生继发性出血。所有胃十二指肠动脉栓塞/支架治疗中（40 名患者中的 8 名，包括 13%（13 名患者中的 3 名）的经验性治疗）有 20%（8 名患者）出现显著并发症（7 名肝梗死，4 名胆管狭窄），90 天死亡率为 38.5%（n=5），并发症患者与无并发症患者（n=6；P=0.008）。出血患者 90 天死亡率为 12.2%（n=11），其中 3 名患者（20%）为原发性胃十二指肠动脉，其余 8 名患者（10.7%）；无出血患者 90 天死亡率为 2%（n=59）。
结论：在这项研究中，胰十二指肠切除术后出血罕见，范围广泛，胃十二指肠动脉仅占出血事件的少数。在近期出血无明显后遗症的情况下，经验性胃十二指肠动脉栓塞/支架治疗与显著的发病率和再出血有关，不应作为常规治疗。成功治疗胰十二指肠切除术后出血需要仔细评估所有潜在的出血源，即使在胃十二指肠动脉缓解后也是如此。
