Management of Massive Arterial Hemorrhage After Pancreatobiliary Surgery: Does Embolotherapy Contribute to Successful Outcome?

Massive arterial hemorrhage is, although unusual, a life-threatening complication of major pancreatobiliary surgery. Records of 351 patients who underwent major surgery for malignant pancreatobiliary disease were reviewed in this series. Thirteen patients (3.7%) experienced massive hemorrhage after surgery. Complete hemostasis by transcatheter arterial embolization (TAE) or re-laparotomy was achieved in five patients and one patient, respectively. However, 7 of 13 cases ended in fatality, which is a 54% mortality rate. Among six survivors, one underwent selective TAE for a pseudoaneurysm of the right hepatic artery (RHA). Three patients underwent TAE proximal to the proper hepatic artery (PHA): hepatic inflow was maintained by successful TAE of the gastroduodenal artery in two and via a well-developed subphrenic artery in one. One patient had TAE of the celiac axis for a pseudoaneurysm of the splenic artery (SPA), and hepatic inflow was maintained by the arcades around the pancreatic head. One patient who experienced a pseudoaneurysm of the RHA after left hemihepatectomy successfully underwent re-laparotomy, ligation of RHA, and creation of an ileocolic arterioportal shunt. In contrast, four of seven patients with fatal outcomes experienced hepatic infarction following TAE proximal to the PHA or injury of the common hepatic artery during angiography. One patient who underwent a major hepatectomy for hilar bile duct cancer had a recurrent hemorrhage after TAE of the gastroduodenal artery and experienced hepatic failure. In the two patients with a pseudoaneurysm of the SPA or the superior mesenteric artery, an emergency re-laparotomy was required to obtain hemostasis because of worsening clinical status. Selective TAE distal to PHA or in the SPA is usually successful. TAE proximal to PHA must be restricted to cases where collateral hepatic blood flow exists. Otherwise or for a pseudoaneurysm of the superior mesenteric artery, endovascular stenting, temporary creation of an ileocolic arterioportal shunt, or vascular reconstruction by re-laparotomy is an alternative.     

Postpancreatoduodenectomy Hemorrhage Treated by Combined Transcatheter Arterial Embolization and Superior Mesenteric Artery to Iliac Artery Bypass: Report of a Case

Postpancreatectomy hemorrhage is a potentially life-threatening complication. We report herein our experience with a 65-year-old man with locally advanced pancreatic adenocarcinoma who underwent pancreatoduodenectomy with lymphadenectomy following neoadjuvant chemoradiotherapy. On postoperative day 45, he developed massive hematemesis. Angiography revealed active bleeding from the common hepatic artery, and transcatheter coil embolization of that vessel was successfully performed. On postoperative day 64, he again developed massive hematemesis. Angiography revealed active bleeding from the proximal superior mesenteric artery. Immediately after coil embolization of that vessel, bypass grafting between the superior mesenteric artery and the right common iliac artery was performed, using a greater saphenous vein graft. The combination of embolization and bypass grafting is an option for treatment of bleeding from the superior mesenteric artery in an emergent situation.Key words: Superior mesenteric artery, Bleeding, Bypass, Pancreatoduodenectomy, Postpancreatectomy hemorrhagePostpancreatectomy hemorrhage (PPH) is a rare but life-threatening complication, often associated with the presence of a pancreatic fistula or intraabdominal abscess.¹ The mortality associated with arterial bleeding after pancreatoduodenectomy is reportedly between 14.3% and 30.7%.^2–6 With recent advances in interventional radiology techniques, transcatheter arterial embolization (TAE) has become an alternative to surgical treatment.^3,5,7,8 However, it may be difficult to treat these patients with interventional radiology techniques alone, given their often unstable condition. In addition, the inappropriate use of TAE for arterial bleeding, especially after pancreatoduodenectomy, can lead to end-organ infarction and subsequent infection. We report herein our experience with a patient who had bleeding from the superior mesenteric artery (SMA) after pancreatoduodenectomy. This patient was successfully treated using SMA coil embolization followed by creation of an SMA-iliac artery bypass using a greater saphenous vein graft.     

肝胆胰术后迟发性出血的诊治分析

目的 探讨肝胆胰术后迟发性出血的原因和诊断治疗方法。方法 回顾性分析宁夏回族自治区人民医院2015年1月至2022年3月收治的13例肝胆胰腺术后出血患者的临床资料和诊治方法,总结其出血的原因和治疗经验。结果 13例患者均有失血性休克临床表现,其中8例为消化道出血：7例为肝动脉分支假性动脉瘤破裂,1例为胆道出血;5例腹腔出血。13例患者动脉造影明确出血部位后行出血部位动脉栓塞治疗,12例出血停止痊愈。另1例患者动脉栓塞治疗失败后,行开腹行肝右动脉结扎止血术后止血。结论 假性动脉瘤形成、胰漏和腹腔感染是肝胆胰患者术后迟发性出血的主要原因。血管造影术是诊断患者术后出血重要的检查方法,动脉栓塞术是治疗术后出血的有效方法。     

Splenic Artery Switch for Revascularization of the Liver: A Salvage Procedure for Inflammatory Arterial Hemorrhage

Background

Hemorrhage caused by inflammatory vessel erosion represents a life-threatening complication after upper abdominal surgery such as pancreatic head resection. The gold standard therapeutic choice is an endovascular minimally invasive technique such as embolization or stent placement. Hepatic arterial hemorrhage in presence of pancreatitis and peritonitis is a particular challenge is if a standard therapeutic option is not possible.

Methods

The management of five patients with massive bleeding from the common hepatic artery is described. All patients underwent a splenic artery switch. The splenic artery was dissected close to the splenic hilum and transposed end-to-end to the common hepatic artery after resection of the eroded part. Patients’ medical records, radiology reports, and images were reviewed retrospectively. Technical success was defined as immediate cessation of hemorrhage and preserved liver vascularization. Clinical success was defined as hemodynamic stability and adequate long-term liver function.

Results

Total pancreatectomy and splenectomy were performed in four of the five cases. Hemodynamic stability and good liver perfusion was achieved in these patients.

Conclusions

Splenic artery switch is an effective, safe procedure for revascularization of the liver in case of hepatic arterial hemorrhage following pancreatic surgery, pancreatitis, and/or peritonitis. The technique is a promising option if a standard procedure—e.g., stent implantation, embolization and surgical repair with alloplastic prosthesis or autologous venous interposition graft—is not possible.     

MSCTA指导下急诊动脉栓塞治疗消化道大出血

目的探讨MSCTA指导下行急诊动脉栓塞治疗消化道大出血的临床价值。方法对14例消化道大出血病例,术前在抗休克治疗同时急诊行MSCTA检查,明确出血部位或出血动脉后行急诊动脉栓塞术,超选择插管至出血动脉支,并以明胶海绵颗粒进行栓塞。结果动脉栓塞后,12例患者有效控制了出血,休克得到纠正。1例明确出血部位及性质后行急诊手术治疗,1例疑静脉出血,后行急诊内镜治疗。结论MSCTA指导下行急诊动脉栓塞术治疗消化道大出血简便迅速、准确性高、安全性好、并发症少。     

肝破裂修补术后再出血的急诊肝动脉栓塞治疗

目的探讨介入栓塞疗法在肝破裂修补术后再出血中的应用价值。方法8例患者于术后5～18h经保守治疗血流动力学仍不稳定,行血管造影显示肝动脉分支有活动性出血,采用Seldinger技术穿刺,使用明胶海绵和弹簧圈经导管栓塞止血。结果8例患者急诊介入栓塞治疗后出血明显减少,效果明显。结论介入栓塞治疗具有创伤小,见效快,相对简单安全等优点,是肝破裂修补术后再出血的一种有效的治疗手段。     

血管介入技术在严重肝外伤损伤控制中的应用

目的 探讨血管介入技术(肝动脉造影及栓塞)在损伤控制性处理严重肝外伤中的应用价值。方法 对13例损伤控制性处理后的严重肝外伤病人进行血管造影,观察是否有再出血的表现,并对出血动脉进行选择性的栓塞。观察止血效果。结果 13例肝动脉造影显示2例胆道出血,5例肝外伤创面出血,3例假性动脉瘤形成,3例无出血征象。10例进行了出血肝动脉分支栓塞均成功止血。随访3个月至2年,无再出血病例及死亡病例。结论 血管介入技术是诊断严重肝外伤行损伤控制性处理后是否再出血以及有效的止血方法。     

经导管肝动脉α-氰基丙烯酸正丁酯胶栓塞治疗肝内出血

目的探讨以α-氰基丙烯酸正丁酯胶(NBCA)作为栓塞剂经导管肝动脉栓塞治疗肝内出血的价值。方法收集接受经导管肝动脉栓塞治疗的肝动脉出血患者7例,均使用NBCA作为栓塞剂,评价技术成功率、临床有效率及相关并发症。结果造影显示假性动脉瘤6例,对比剂外溢1例。对7例患者均成功施行经导管肝动脉栓塞术,术后即刻造影假性动脉瘤和对比剂外溢征象消失,技术成功率100%;NBCA及超液化碘油混合剂用量为(0.76±0.24)ml;术后患者腹痛症状缓解,血红蛋白浓度升高,临床有效率100%。未发生手术相关并发症,随访1个月无再出血病例。结论采用NBCA胶行经导管肝动脉栓塞治疗肝内出血安全有效,具有重要临床应用价值。     

急诊经导管动脉栓塞治疗医源性肝动脉出血

目的探讨医源性肝动脉出血的急诊肝动脉造影表现及经导管动脉栓塞(TAE)治疗的疗效。方法对38例医源性肝动脉出血患者行急诊肝动脉造影,确定出血动脉后,以明胶海绵、PVA颗粒和弹簧圈进行急诊栓塞治疗;对其急诊肝动脉造影表现及TAE疗效进行回顾性分析。结果 38例中,21例肝动脉造影可见对比剂外溢,5例肝动静脉瘘,9例肝动脉假性动脉瘤,3例肝动脉假性动脉瘤合并肝动静脉瘘。急诊TAE后38例出血均停止,总有效率为100%(38/38)。1例术后10天复发出血,再次栓塞治疗后出血停止。随访12个月,所有患者均无肝脏坏死及异位栓塞等严重并发症发生。结论急诊TAE治疗医源性肝动脉出血安全、有效。     

经导管动脉栓塞术治疗妇产科急症出血的疗效观察

目的评价经导管动脉栓塞术治疗妇产科急症出血的临床疗效。方法选择性双侧髂内动脉或超选择性子宫动脉插管，以真丝线段和明胶海绵颗粒栓塞双侧子宫动脉，明胶海绵条栓塞双侧髂内动脉。结果对27例妇产科急症出血患者进行了动脉栓塞，其中15例进行双侧子宫动脉栓塞，7例进行双侧髂内动脉栓塞，5例进行双侧子宫动脉和髂内动脉同时栓塞。25例完全彻底止血，2例剖宫产栓塞后再出血，未出现严重并发症。结论经导管动脉栓塞术是治疗妇产科急症出血的可靠方法。同时栓塞双侧子宫动脉和双侧髂内动脉能提高止血效果。     

Successful embolization assisted by covered stents for a pseudoaneurysm following pancreatic surgery

Delayed intra-abdominal hemorrhage after pancreatic surgery is a potentially lethal complication. Transarterial coil embolization and/or the placing of an endovascular stent are minimally invasive and effective procedures. An artery that is extensively eroded and rendered friable due to operative skeletonization or postoperative inflammation sometimes contributes to delayed intra-abdominal hemorrhage or rebleeding after coil embolization. This report presents a case of successful management of postoperative hemorrhage in a-74-year-old Japanese male. He experienced bleeding from a pseudoaneurysm of the brittle hepatic artery following total pancreatectomy. Initially the pseudoaneurysm was successfully treated with covered coronary stent-grafts, but rebleeding occurred 1 mo later due to the brittleness of the artery. Rebleeding was definitively managed by the complete packing of the stent by coil embolization. He remains stable at 18 mo following the final embolization. A stent graft can be used for protecting a brittle artery to avoid injury by coil embolization.     

Acute clinical pancreatitis following selective transcatheter arterial chemoembolization of hepatocellular carcinoma

Acute pancreatitis can complicate non-selective transcatheter arterial embolization of hepatocellular carcinoma with an incidence ranging from 1,7% (acute clinical pancreatitis) to 40% (biological pancreatitis). This complication is thought to be related to embolization of extrahepatic arterial collaterals.We report herein a case of acute clinical pancreatitis developing within 24 hours after a second course of selective transcatheter arterial chemo-embolization into the proper hepatic artery. Neither anatomical arterial variation nor particular risk factor for acute pancreatitis could be identified. This complication is unusual after selective arterial embolization. Because it may clinically mimick a postembolization syndrome, dosage of serum pancreatic enzymes should be performed systematically in case of abdominal pain following chemoembolization.     

选择性出血动脉栓塞治疗创伤性肝脏破裂出血

目的 探讨选择性出血动脉栓塞在处理创伤性肝脏破裂出血中的止血效果.方法 回顾性分析2004年1月至2011年6月期间笔者所在医院收治的63例创伤性肝脏破裂出血患者的临床资料,均首先采用股动脉穿刺插管,肝动脉造影显示出血部位,然后将微导管放至出血分支动脉,注入栓塞剂,选择性栓塞止血.结果 63例均顺利完成肝动脉造影,显示肝左动脉分支出血8例,肝右动脉分支出血39例,肝左、右动脉分支均有出血10例,6例未见明确出血.57例出血患者均完成栓塞并成功止血,其中1处栓塞36例,2处栓塞11例,3处及以上栓塞10例.6例无明确出血表现者未做栓塞.无继发出血病例,无死亡病例.栓塞后1周血红蛋白及红细胞比容基本恢复正常.63例随访0.5～1年,无肝脏再出血,肝功能正常.结论 选择性出血动脉栓塞是治疗创伤性肝脏破裂出血的一种安全、有效以及微创的手段.     

经动脉介入栓塞治疗颅面部创伤性大出血

目的探讨经动脉介入栓塞治疗颅面部创伤致急性、难治性大出血的临床疗效及价值。方法 32例颅面部创伤患者中,颅底骨折致口、鼻、耳道大出血28例,面颅骨骨折致口、鼻大出血4例,所有患者经动脉造影确定出血靶血管及范围后接受经动脉介入栓塞治疗,并评价其疗效。结果 32例均成功止血,未出现严重并发症。结论经动脉介入栓塞治疗颅面部创伤致急性大出血,创伤小、止血迅速、安全有效,可成为临床首选治疗方法。     

经导管选择性动脉栓塞治疗创伤性假性动脉瘤

目的探讨经导管选择性动脉栓塞治疗损伤性假性动脉瘤的疗效。方法 16例损伤性出血患者,其中肾脏出血5例,肝脏出血3例,剖宫产后出血4例,切口妊娠流产1例,宫颈癌放疗后出血1例,骨外伤术后出血2例。采用经股动脉穿刺选择性插管进行靶动脉造影及栓塞治疗。采用明胶海绵和（或）弹簧钢圈栓塞瘤腔及供血动脉。结果全部患者动脉造影均见假性动脉瘤,其中2例伴有动静脉瘘。栓塞成功率100%,栓塞后即刻造影示假性动脉瘤消失,止血成功率93.75%。术后均未发生严重并发症,随防6个月均无复发。结论经导管选择性动脉栓塞治疗损伤性假性动脉瘤性出血安全有效、创伤小、并发症少,是可靠的治疗方法 。     

介入诊疗急性动脉性消化道大出血

目的探讨急性动脉性消化道大出血介入诊疗的临床应用价值。方法对39例急性动脉性消化道大出血患者行DSA检查,对38例出血征象阳性的患者中37例采用明胶海绵颗粒配合微弹簧圈进行介入栓塞治疗。结果 39例动脉造影中38例出血征象阳性,主要表现为对比剂外溢。接受栓塞治疗的37例中,止血成功36例(其中3例行第2次栓塞),均未发生与介入栓塞相关的严重并发症。最终2例患者转剖腹探查手术。结论介入技术是急性动脉性消化道大出血安全、有效的诊疗手段,能快速明确出血动脉及部位,并迅速有效控制出血。     

Diagnosis and Treatment of Abdominal Arterial Bleeding After Radical Gastrectomy: a Retrospective Analysis of 1875 Consecutive Resections for Gastric Cancer

Background

Massive abdominal arterial bleeding is an uncommon yet life-threatening complication of radical gastrectomy. The exact incidence and standardized management of this lethal morbidity are not known.

Methods

Between January 2003 and December 2013, data from 1875 patients undergoing radical gastrectomy with D2 or D2 plus lymphadenectomy were recorded in a prospectively designed database from a single institute. The clinical data and management of both early (within 24 h) and late (beyond 24 h) postoperative abdominal arterial hemorrhages were explored. For late bleeding patients, transcatheter arterial embolization (TAE) and re-laparotomy were compared to determine the better initial treatment option.

Results

The overall prevalence of postoperative abdominal arterial bleeding was 1.92 % (n?=?36), and related mortality was 33.3 % (n?=?12). Early and late postoperative bleedings were found in 6 and 30 patients, respectively. The onset of massive arterial bleeding occurred on average postoperative day 19. The common hepatic artery and its branches were the most common bleeding source (13/36; 36.1 %). All the early bleeding patients were treated with immediate re-laparotomy. For late bleeding, patients from the TAE group had a significantly lower mortality rate than that of the patients from the surgery group (7.69 vs. 56.25 %, respectively, P?=?0.008) as well as a shorter procedure time for bleeding control (2.3?±?1.1 vs. 4.8?±?1.7 h, respectively, P?<?0.001). Four rescue reoperations were performed for TAE failures; the salvage rate was 50 % (2/4). Ten patients developed massive re-bleeding after initial successful hemostasis by either TAE (5/13) or open surgery (5/16). Three out of the 10 re-bleeding patients died of disseminated intravascular coagulation (DIC), while the other 7 recovered eventually by repeated TAE and/or surgery.

Conclusion

Abdominal arterial bleeding following radical gastrectomy tends to occur during the later phase after surgery, with further complications such as abdominal infection and fistula(s). For late bleeding, TAE can be considered as the first-line treatment when possible.

     

外伤性肝脏出血的血管造影诊断和栓塞治疗

目的探讨外伤性肝脏出血的DSA诊断与介入栓塞治疗的临床应用价值。方法对18例肝脏外伤出血患者行急诊动脉DSA检查和介入栓塞止血治疗,栓塞材料采用明胶海绵和（或）聚乙烯醇（PVA）微粒。结果18例DSA检查出血表现为造影剂外溢,均获得了明确诊断。18例栓塞治疗后出血均立即停止,1例在治疗后24h内出血复发,遂行二次栓塞止血成功。随访3个月,无复发出血。未见严重并发症发生。结论DSA能及时、准确的发现肝脏出血的部位,是诊断外伤性肝脏出血的可靠方法。介入栓塞术治疗外伤性肝脏出血安全、迅速、有效,并能最大限度保护肝脏功能。     

经皮肝穿刺胆管引流术后胆道大出血的介入治疗

目的探讨介入疗法治疗经皮肝穿刺胆管引流术（PTCD）后胆道大出血的临床应用价值。 方法回顾性分析2008年3月至2015年1月621例因胆道梗阻行PTCD,共发生术后胆道大出血8例（1.29%）,7例患者首选经选择性血管造影及引流管造影,证实责任血管后行介入治疗。1例先行手术探查,术后再发大出血,予血管造影检查证实假性动脉瘤后行介入治疗。 结果6例患者经造影证实为医源性血管损伤,其中2例为动脉胆管瘘,3例为假性动脉瘤,1例为门静脉胆管瘘。2例动脉胆管瘘及3例假性动脉瘤患者予栓塞责任血管近端、远端后治愈,门静脉胆管瘘患者经保守治疗后死亡。剩余2例为胆管癌栓松动后自发出血,经肝动脉栓塞后止血。 结论血管介入治疗为胆道大出血的首选治疗方法,具有安全性高、创伤小、疗效确切的优势。     

Arteriographic embolization of visceral artery pseudoaneurysms

The purpose of this study was to determine the safety and efficacy of transcatheter embolization in the management of bleeding visceral artery pseudoaneurysms. Eight patients (four women and four men) whose mean age was 61.0 years (range 44 to 77 years) underwent emergency transcatheter embolization for acute hemorrhage from a visceral artery pseudoaneurysm. Arteriographic technique was used to localize and selectively embolize these seven visceral artery pseudoaneurysms (three inferior pancreaticoduodenal, one gastroduodenal, two hepatic, and one splenic) by means of intravascular steel coils. Arteriography demonstrated visceral artery pseudoaneurysms in all eight patients. Acute hemorrhage was documented by endoscopy, falling hematocrit levels, CT scans, and arteriography. Successful embolization of these visceral artery pseudoaneurysms was achieved in seven (88%) of eight patients. In one patient embolization was not attempted because of a worsening clinical status, and this patient subsequently underwent emergency surgical resection. There was no significant morbidity associated with the procedures and seven patients remain asymptomatic with no further bleeding at a mean follow-up of 21.1 months (range 11 to 46 months). Arteriographic embolization of visceral artery pseudoaneurysms is a safe and highly successful technique for the effective identification and treatment of hemorrhage even in critically ill patients.