Delayed massive arterial hemorrhage after pancreaticoduodenectomy for cancer. Management of a life-threatening complication.

Abstract

Delayed massive arterial hemorrhage from the operating field occurs in 1-4% of cases after pancreaticoduodenectomy, with a mortality rate up to 50%. The purpose of this study was to define diagnostic and treatment methodologies to maximize survival. Between 1990 and 1999, 84 pancreaticoduodenectomies were performed for periampullary and pancreatic head cancer. After surgery, massive bleeding occurred in two patients (2.3%), 30 and 8 days after resection, respectively. Pancreatic leak and disruption of the pancreaticojejunostomy were reported in both cases. Bleeding was controlled by suture ligation of the stump of the gastroduodenal artery. Completion pancreatectomy and a new pancreaticojejunostomy were respectively performed. Hemorrhage recurred in both cases from a ruptured pseudoaneurysm of the hepatic artery, requiring re-exploration and surgical ligation. The first patient died of re-bleeding despite completion pancreatectomy, the other survived after oversewing the residual pancreatic stump at re-exploration. Early diagnosis and management of pancreatic leak represents the only means to prevent a delayed massive arterial hemorrhage. Transarterial embolization or surgical ligation of the hepatic artery proximal to the celiac axis represents the procedure of choice to control the bleeding. Taking down the pancreatic anastomosis and oversewing the pancreatic stump is safe and effective. Extensive drainage of the operating field should always be associated to prevent multisystem organ failure.