Abstract: Objective:To explore the diagnosis, treatment, risk factors and prognosis factors of postpancreaticoduodenectomy hemorrhage (PPH).
Methods:The retrospective casecontrol study was adopted. The clinical data of 703 patients who underwent pancreatoduodenectomy at Hospital 401 of the People′s Liberation Army from January 2008 to July 2013 were collected. Standard pancreatoduodenectomy was carried out for the malignant tumors of the head of pancreas or ampulla, pyloruspreserving pancreatoduodenectomy was operated for the benign tumor or the duodenal papilla tumor. The corresponding treatment was adopted for PPH. The observation indicators included: (1) the surgical situation (surgical method, operation time and the volume of intraoperative blood loss), (2) diagnosis of PPH, (3) treatment of PPH, (4) univariate and multivariate analyses for the risk factors affecting the occurrence of PPH, (5) univariate and multivariate analyses for the risk factors affecting prognosis of PPH patients. The measurement data with normal distribution were represented as ±s. The measurement data with skewed distribution were represented as M (range). The chisquare test or Fisher exact probability was used for univariate analysis. Logistic regression model was used for multivariate analysis.
Results: (1) The surgical situation: among 703 patients, 409 patients underwent standard pancreatoduodenectomy and 294 underwent pyloruspreserving pancreatoduodenectomy, including 1 combined with right hemihepatectomy, 27 with portal vein reconstruction and 2 with hepatic artery reconstruction. Pancreaticojejunostomy was applied to 658 patients using mucosa anastomosis of the pancreatic duct to jejunum and 45 patients using invagination anastomosis. Supporting tube was routinely deposed in the pancreatic duct, 598 patients had internal drainage and 105 patients had external drainage. The endtoside anastomosis between common bile duct and jejunum was used for choledochojejunostomy. The 409 patients received the gastrojejunostomy using sidetoside anastomosis of gastric part and jejunum and 294 patients using endtoside anastomosis of duodenum and jejunum. Operation time and volume of intraoperative blood loss were (324±54)minutes and (428±118)mL. (2) The diagnosis of PPH: among 703 patients after pancreatoduodenectomy, 62 patients had PPH, the hemorrhage reasons of 38 patients had been identified, and the hemorrhage reasons of 24 patients had not been identified ( A level in 5 patients, B level in 17 patients, C level in 2 patients). ① The site of hemorrhage: the hemorrhage outside the cavity were detect in 27 patients, the hemorrhage inside the cavity in 28 patients, and the hemorrhage from both outside and inside part of the cavity in 7 patients. ② The time of hemorrhage: earlystage hemorrhage were detected in 5 patients and the delayed hemorrhage in 57 patients. ③The volume of postoperative blood loss was (885±253)mL, 30 patients had mild hemorrhage and 32 patients had severe hemorrhage. ④ The clinical classification of PPH: 5, 32 and 25 patients were detected in level A, B, C, and 19 patients combined with sentinel hemorrhage. (3) The treatment of PPH: ① 5 patients with PPH in A level were given clinical observation, blood volume supplement and other treatment, then the symptoms gradually turned better. ② Among 32 patients with PPH in B level, 15 patients became better after symptomatic and supportive treatments, 6 patients received successful hemostasis after guglielmi detachable colis embolization, 4 patients received successful hemostasis under gastroscopic hemostasis,7 patients received emergency exploratory laparotomy. Thirtytwo patients were improved and then out of hospital after treatment, without occurrence of death. ③ Among 25 patients with PPH in C level, 4 patients received successful hemostasis after guglielmi detachable colis embolization, 17 patients received hemostasis by emergency exploratory laparotomy, 4 patients with undiscovered bleeding points received the treatment of fluid infusion, blood volume supplement and antacid. Among 25 patients after corresponding treatment, 10 patients were improved and 15 patients were dead. (4) The result of univariate analysis showed that the combined hypertension, vascular resection and reconstruction, postoperative pancreatic leakage and postoperative intraabdominal infection were risk factors affecting the occurrence of PPH (χ²=4.950, 5.300, 7.568, 5.505, P<0.05). The results of multivariate analysis showed that the combined pancreatic leakage and postoperative intraabdominal infection were independent risk factors affecting the occurrence of PPH ［OR=2.761, 2.216, 95% confidence interval (CI): 1.389-5.489, 1.198-4.101, P<0.05］. (5) The risk factors affecting the prognosis of PPH patients: the results of univariate analysis showed that postoperative sentinel hemorrhage, postoperative pancreatic leakage, site, degree and level of hemorrhage were risk factors affecting the prognosis of PPH patients (χ²=8.022, 4.448, 11.853, 18.551, 28.285, P<0.05). The results of multivariate analysis showed that postoperative sentinel hemorrhage and site of hemorrhage (outside and inside part of the cavity) were independent risk factors affecting the prognosis of PPH patients (OR=5.550, 0.233, 95% CI: 1.595-19.314, 0.086-0.635, P<0.05).
Conclusions:Pancreatic leakage and intraabdominal infection are independent risk factors after pancreatoduodenectomy. The treatment effect of the earlystage hemorrhage is better than that of the delayed hemorrhage, and angiographic embolization is the first choice of diagnosis and treatment for the delayed hemorrhage. Sentinel hemorrhage could result from aneurysm or continuous arterial hemorrhage of vascular erosion, it is the independent risk factor affecting the death of hemorrhage after pancreatoduodenectomy.