Post-pancreaticoduodenectomy hemorrhage. Incidence, diagnosis, and treatment.

BACKGROUND: Although mortality post-pancreaticoduodenectomy (PD) has decreased, morbidity rates continue to be high, ranging from 30% to 50%. Among complications, hemorrhage stands out; it is associated with high mortality and there is no standard management. The aim of the present study was to analyze the incidence, diagnosis, and treatment of hemorrhage post-cephalic PD at our center. METHODS: From January 2005 to December 2008, 107 PDs were performed. A retrospective review of characteristics of patients with postoperative hemorrhage was made from our prospective database. Demographic data, diagnosis, treatment (medical, laparotomy, interventional radiology), association with fistula (pancreatic or biliary), intra- or extraluminal hemorrhage, bleeding time (early or late), severity (moderate/severe), and mortality were analyzed. RESULTS: Eighteen patients (18/107; 16.82%) hemorrhaged after PD. Hemorrhage appeared early (< 24 h) in 4 of these 18 patients (22.2%), and it was severe in 13/18 (72%). Hemorrhage-related mortality was 11% (2/18) and hospital mortality was 22.2% (4/18). Arteriography was performed in 8/18 patients (44.4%) and was effective in 6/8 (75%); laparotomy was performed in 8/18 (44.4%). Re-bleeding occurred in 5 of these 18 patients after the first treatment (27.8%). An association between hemorrhage and fistula was observed. CONCLUSIONS: Hemorrhage after pancreatic resection must be considered a complication with relatively high mortality. Diagnosis should be established and treatment applied rapidly. Pancreatic and/or biliary fistulae were significantly associated with a higher risk of postoperative hemorrhage. Interventional radiology is a good therapeutic option.

[Usefulness of erythromycin in severe postoperative gastroparesis]. / Utilidad de la eritromicina en la gastroparesia postquirúrgica severa.

Erythromycin has recently been shown to exert a great effect on gastroduodenal motor activity. This prokinetic action may be clinically useful in patients with gastrointestinal hypomotility such as diabetic or postsurgical gastroparesis. The case of a diabetic patient who underwent antrectomy Billroth II for gastric cancer is presented. Severe gastroparesis appeared after surgery and nasogastric aspiration could not be removed, although the patient was treated with metoclopramide, and glucose levels, hydroelectrolytic balance and nutritional status were corrected. Forty-one days after the first operation, a second gastrectomy with Bilroth II reconstruction was performed because of supposed anastomotic narrowing, which was not confirmed at surgery. Fourteen days later, i.v. erythromycin (200 mg/4h) was started owing to gastroparesis persistence. Six days after treatment the patient tolerated oral ingestion. Prokinetic drugs constitute the specific therapy for gastroparesis. Metoclopramide is the most used, although its efficacy is limited. In the last few years, erythromycin has proved to have a powerful effect on gastroduodenal motility. This effect is mediated, at least in part, by its motilin stimulating activity accelerating gastric emptying. Our patient completely recovered from gastroparesis after erythromycin treatment. Recent results of erythromycin therapy in these patients have been promising, despite the difficult management involved.

[Cystic lymphangioma of the stomach. Report of a new case]. / Linfangioma quístico de estómago. Aportación de un nuevo caso.

Cystic lymphangioma are rare benign tumours which are manifested as unilocular o multilocular masses containing chylous or serous material. Its origin is generally accepted to be a congenital lymphatic inflammation. It is difficult to make a preoperative diagnosis. Occasionally, when these lesions are suspected, they may be diagnosed by lymphography. We describe one case which underwent subtotal gastrectomy. At the microscopic examination dilated lymphatic channels were present with some lymphatic inflammation.