Management of a Bleeding Pseudoaneurysm after Pancreaticoduodenectomy: 27 cases experience in single-center

ABSTRACT

PURPOSE: Delayed massive hemorrhages from pseudoaneurysm rupture of the peripancreatic large arteries, after pancreaticoduodenectomy, are fatal. We reviewed the clinical course and outcome of bleeding pseudoaneurysms after pancreaticoduodenectomy. METHOD: The medical records of 905 consecutive patients who underwent pancreaticoduodenectomies between October 1994 and February 2007 were reviewed retrospectively. In 27 cases with hemorrhagic complications, pseudoaneurysms were diagnosed as the main cause of bleeding. The clinical characteristics, course, management, and outcomes were reviewed. RESULT: In 27 cases (3.0%) of the 905, the bleeding pseudoaneurysms were diagnosed by angiography, during surgery or clinically. In 11 cases, the hemorrhage was from the pseudoaneurysm on the ligated gastroduodenal artery-stump, in five it was from the right hepatic artery, in four from the proper hepatic artery or common hepatic artery, and two from the right gastric artery. Twelve cases had pancreatic leakage. Sentinel bleedings were observed in 21 cases, there were 11 cases of bleeding from the surgical drains, eight cases from the GI tract, and in two cases from both. In 23 cases, arterial embolization was attempted and 18 cases were successful. Four cases had secondary pseudoaneurysmal bleeding. After embolization at the common or proper hepatic artery, six cases had liver abscess or infarction and there was one case of hepatic failure. CONCLUSION: Delayed massive hemorrhage after pancreaticoduodenectomy should be ruled out to determine whether it is associated with an arterial pseudoaneurysm rupture. Transcatheter arterial embolization is an effective modality for control of the bleeding from an arterial pseudoaneurysm.