Hemorrhage after laparoscopic pancreaticoduodenectomy: causes and countermeasures / 中华肝胆外科杂志

ABSTRACT

Objective:To study the causes of hemorrhage after laparoscopic pancreaticoduodenectomy (LPD) and to develop countermeasures in its prevention.Methods:The clinical data of 215 patients who underwent LPD at the Department of Hepatobiliary and Pancreatic Surgery of Zhejiang Provincial People's Hospital from December 2013 to May 2020 were reviewed. The patients’ clinical data including gender, age, comorbidities and postoperative complications such as bleeding, pancreatic fistula, biliary fistula and intraperitoneal infection were studied, with the aims to analyze the causes, clinical manifestations and treatment results of post-pancreaticoduodenectomy hemorrhage (PPH) after LPD.Results:Of 215 patients, there were 132 males and 83 females, aged (60.7±10.3) years. PPH occurred in 20 patients, incidence rate was 9.30%(20/215). Early hemorrhage was mainly caused by inadequate hemostasis or loosening of vascular clips, while delayed hemorrhage was mainly caused by gastrointestinal fistula with vascular erosion, arterial injury by intraoperative energy instruments or pseudoaneurysms. Among the 20 patients, 6 patients had early hemorrhage and 14 delayed hemorrhage. There was 1 patient with grade A, 10 with grade B and 9 with grade C hemorrhage. Thirteen patients developed pancreatic fistula, 1 biliary fistula, and 2 intraperitoneal infection. One patient responded well to conservative treatment. Hemostasis was successfully achieved by gastroscopy ( n=1) and interventional therapy ( n=7). Eleven patients required laparotomy for hemostasis. In this study, 14 of 20 patients survivied PPH and 6 patients died. The mortality rate was 30% (6 of 20 patients with PPH). Conclusions:Early hemorrhage was caused by inadequate hemostasis or loosening vascular clips, while delayed hemorrhage was related to gastrointestinal fistula with vascular erosion, arterial injury by intraoperative energy instrument or pseudoaneurysm. Careful hemostasis, adequate protection of blood vessels, and accurate anastomosis should be performed in LPD. DSA angiography should be used for arterial hemorrhage which progressed very rapidly. Interventional therapy including embolism and stenting were means to control arterial bleeding in PPH. Decisive surgical exploration when interventional therapy failed was important in reducing the mortality rate of these patients.