Strategy and management of severe hemorrhage complicating pancreatitis and post-pancreatectomy.

Diagn Interv Radiol 2019; 25: 81–89 I N T E R V E N T I O N A L R A D I O LO G Y © Turkish Society of Radiology 2019 ORIGINAL ARTICLE Strategy and management of severe hemorrhage complicating pancreatitis and post-pancreatectomy Chao Zhang* Ang Li* Tao Luo* Jia Li Diangang Liu Feng Cao Jianxin Li Fei Li PURPOSE Transcatheter arterial embolization (TAE) is increasingly used as the first-line treatment for hemorrhage complicating pancreatitis and post-pancreatectomy. However, the optimal therapeutic strategy remains unclear. METHODS Among 1924 consecutive patients, 40 patients with severe pancreatic hemorrhage in Xuanwu Hospital were enrolled between 2005 and 2017. Patients underwent angiography and direct TAE for primary diagnosis and treatment of bleeding. Repeat TAE, watch and wait, and laparotomy were used as the other therapeutic options. Patient data, technical success, and 90-day survival were identified. RESULTS Pancreatic diseases underlying hemorrhage included acute pancreatitis (n=19, 47.5%), chronic pancreatitis (n=12, 30%), and pancreatic cancer (n=9, 22.5%). A history of percutaneous catheter drainage or pancreatic surgery was seen in 29 patients (72.5%). There were 48 angiographies, 31 embolizations, and 5 laparotomies performed. Rebleeding occurred in 8 patients (20%); 4 of whom underwent re-embolization, 3 had laparotomy, and 1 had conservative treatment. Successful clinical hemostasis was achieved in 37 patients. Complications were observed in only 2 patients with renal failure and 1 patient with hepatic insufficiency. In total, 25 patients (62.5%) were alive at the 90-day follow-up. CONCLUSION Endovascular management is effective for achieving hemostasis in severe pancreatic hemorrhage with a high success rate and low recurrence, and laparotomy is not suitable for rebleeding cases. P From the Departments of General Surgery (C.Z., A.L., J.L., D.L., F.C., F.L.  ) and Vascular Surgery (T.L., Jianxin.L.) Xuanwu Hospital, Capital Medical University, Beijing, China. *These authors have contributed equally to this work. Received 20 June 2018; accepted 28 July 2018. Published online 17 December 2018. DOI 10.5152/dir.2018.18283 ancreas-associated hemorrhage is an uncommon but severe complication of pancreatic diseases. It includes acute pancreatitis (AP), chronic pancreatitis (CP), and iatrogenic bleeding, such as post-pancreatectomy hemorrhage (PPH) and pancreatic necrosectomy. Since pancreatic enzymes are released during pancreatitis or post-pancreatectomy, vascular structures, particularly the visceral arteries, are corroded by the proteolytic activity of these enzymes. The resulting acute hemorrhage has been recognized as a rapidly lethal condition, and the reported mortality rates range from 40% to 50% in patients with pancreatitis (1, 2) and from 30% to 50% in patients with PPH (3, 4). Recently, owing to rapid diagnoses using angiography and prompt retrieval using endovascular intervention, the mortality rate has been reduced considerably. However, the initial step and overall therapeutic strategy for pancreatic intra-abdominal hemorrhage or bleeding pseudoaneurysm remain controversial, particularly because of the failure to detect the bleeding site and to control the bleeding. Moreover, studies regarding massive hemorrhage are limited to review articles and short case series with the hemostasis methods, which still have no best therapeutic strategy. The aim of the present study was to report a center-specific experience with angiography and transcatheter arterial embolization (TAE) as the first-step choice for the treatment of massive pancreatic hemorrhage, including severe bleeding pseudoaneurysm with AP, CP You may cite this article as: Zhang C, Li A, Luo T, et al. Strategy and management of severe hemorrhage complicating pancreatitis and postpancreatectomy. Diagn Interv Radiol 2019; 25: 81–89. 81 and late PPH, to illustrate the effectiveness of this strategy and to compare the outcomes between the TAE procedures and surgical intervention in the management of pancreatic hemorrhage. Moreover, in the present study, the pre-hemorrhage clinical characteristics and other recent 10-year studies investigating pancreatic hemorrhage were reviewed. Methods This retrospective, observational study was conducted at the Department of General Surgery, Xuanwu Hospital, Capital Medical University. The local ethics committee approved the study according to the Declaration of Helsinki. Informed consent was obtained from each participant. Patient selection A retrospective review of the administrative diagnostic database was performed to identify patients with pancreatitis (International Classification of Disease (ICD)-10 codes K85 and K86) and pancreatic cancer (ICD-10 code C25) who were treated at Xuanwu Hospital of the Capital Medical University between January 2005 and December 2017. The medical records of the patients who underwent an endovascular procedure for acute hemorrhage, including gastrointestinal bleeding (intraluminal) and intraperitoneal bleeding/bleeding in the drainage (extraluminal), were obtained. Patients were enrolled in the study if they met the following criteria: 1) severe extra- or intraluminal hemorrhage in AP and CP associated with clinical shock and a rapid decrease in hemoglobin concentration >30 g/L requiring blood transfusion and 2) late PPH, defined as any hemorrhagic event that occurred >24 h after the end of pancreatic surgery and Main points • The important factors associated with the risk of pancreatic bleeding are pancreatic fistula and iatrogenic injury. • Endovascular techniques could be the opti- mal choice for determining the location of the bleeding diagnosis, and TAE is the main management for hemostasis. • The “two-point” or “sandwich” technique was required to occlude both sides of the arterial arcades, which could minimize the rebleeding risk in the TAE procedure. • Laparotomy is not suitable for rebleeding cases, as it has low technical success rate and survival rate compared with the TAE procedure. graded B or C according to the International Study Group of Pancreatic Surgery (ISGPS) definition (5). Exclusion criteria were as follows: 1) early PPH (<24 h after the end of surgery) caused by insufficient hemostasis; 2) mucosal hemorrhage caused by peptic ulcer, anastomotic ulcer, or anastomotic dehiscence after pancreatic surgery; 3) stress gastrointestinal bleeding, hemorrhage in the abdominal wall vessel or muscle from the sinus tract after surgery or drainage intervention; and 4) direct surgical treatment as the primary treatment for hemorrhage without angiography diagnosis. Medical data regarding the patients’ prehemorrhage clinical characteristics, management, and outcomes were retrospectively analyzed. Angiography and TAE procedure Endovascular treatment was performed if the hemodynamic stability of the patients was successfully maintained by fluids, blood transfusion (packed red blood cells and f (...truncated)