Pseudoaneurysm after Pancreaticoduodenectomy Related with Delayed Massive Hemorrhages

Moon, Hyoun Jong; Chang, Weon Young; Heo, Jin Seok; Choi, Seong Ho; Joh, Jae Won; Kim, Yong Il

Abstract

PURPOSE: Recently, hemorrhages has been accepted the most serious complication with a high mortality after a pancreaticoduodenectomy. In particular, delayed massive hemorrhages that occur from a pseudoaneurysmal rupture at the peripancreatic large arteries are quite formidable. In most patient with pseudoaneurysmal bleeding, sentinel hemorrhages can be observed. Early angiography and transcatheter arterial embolization can be used effectively as initial diagnostic and treatment modalities for a pseudoaneurysm. The authors reviewed the hemorrhagic complications from pseudoaneurysms after a pancreaticoduodenectomy and present the clinical features and treatment modalities
METHODS
Four hundred-fifty-four consecutive patients who underwent a pancreaticoduodenectomy between October 1994 and April 2002 were reviewed by a retrospective evaluation of their medical records. In 8 cases with hemorrhagic complications, pseudoaneurysms were determined by angiography to be the main cause of hemorrhage. The clinical characteristics, pre-hemorrhagic symptoms, treatments and outcomes were analyzed.
RESULTS
Hemorrhagic complications occurred in 35 (7.7%) out of 454 cases of pancreaticoduodenectomy. In 8 (22.8%) out of 35 cases, the hemorrhage burst from the pseudoaneurysms. In 1 out of 8 cases, the hemorrhage originated from a pseudoaneurysm on the proper hepatic artery, 1 case on the right hepatic artery, 1 case on the inferior pancreatoduodenal artery and on ligated gastroduodenal artery-stump in the remainder. Three cases had intra-abdominal complications such as a pancreatic fistula. Sentinel bleeding were observed in 7 cases, bleeding from the surgical drains in 4 cases, hematemesis in 5 cases and melena in 1 case. In all cases, arterial embolization was attempted and 6 cases were successful. Two cases required surgery. There was 1 mortality from hepatic failure after the embolization.
CONCLUSION
Delayed massive hemorrhages after a pancreaticoduodenectomy should be ruled out when determining whether they are associated with an arterial pseudoaneurysmal rupture. Sentinel bleeding, which can be used as a warning sign of pseudoaneurysmal rupture, can be detected with close observation. Transcatheter arterial embolization is an effective modality to control bleeding from an arterial pseudoaneurysm initially.