The role of interventional radiology in the management of surgical complications after pancreatoduodenectomy

Department of Hepatopancreatobiliary Surgery, Ninewells Hospital, Dundee Medical School, Dundee, UK.
HPB (Impact Factor: 2.05). 12/2012; 14(12):812-7. DOI: 10.1111/j.1477-2574.2012.00545.x
Source: PubMed

ABSTRACT This study evaluates the role of interventional radiology (IR) in the management of postoperative complications after pancreatoduodenectomy (PD).
A total of 120 consecutive patients were reviewed to identify IR procedures performed for early complications after PD.
Findings showed that 24 patients (20.0%) required urgent radiological or surgical re-intervention for early complications, including 11 instances of post-pancreatectomy haemorrhage (PPH), six intra-abdominal abscesses, two bile leaks, one pancreatic fistula and one bowel ischaemia. Three of 24 complications were managed by surgery and 21 were managed by IR. Two of 11 PPHs involved intraluminal haemorrhage (ILH) and nine involved intra-abdominal haemorrhage (IAH). One ILH was managed conservatively and one required surgical intervention. In eight of nine patients with IAH, the bleeding site was identified on computed tomography angiography, and endovascular stenting or coil embolization were performed. No patient required a re-look laparotomy following IR for haemorrhage or intra-abdominal abscess. Overall, three of 120 patients required an urgent re-look laparotomy for early complications.
Rates of major morbidity after PD remain high. However, many significant complications (PPH, pancreatic fistula, intra-abdominal abscess) can be managed by IR, reducing the need for reoperation. Re-look surgery is still required in a small percentage (2.5%) of patients.

  • [Show abstract] [Hide abstract]
    ABSTRACT: There is controversy regarding the recommended surgical approach for pancreatic tumors near the neck or proximal body of the pancreas. Unlike pancreatic cancer patients, those with benign and borderline (low-grade) malignant tumors of the pancreas are expected to have long-term survival after successful pancreatic resection. Therefore, surgeons need to consider not only oncologic safety, but also quality of life in their choice of surgical treatment. Laparoscopic central pancreatectomy (CP) is an ideal approach for pancreatic tumors near the neck or proximal body of the pancreas because it preserves endocrine and exocrine pancreatic function and conserves spleen function. Consequentially, CP can improve quality of life. However, there are no standardized studies supporting the use of laparoscopic CP. In this manuscript, we review the current status of minimally invasive CP in the advanced laparoscopic era and assess the quality of the evidence supporting the use of CP. We also propose future directions for scientific efforts to assess the utility of this surgical approach for benign and borderline malignant tumors near the neck of the pancreas.
    Journal of Hepato-Biliary-Pancreatic Sciences 12/2014; 21(12). DOI:10.1002/jhbp.143
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Introduction Operative complications after pancreatoduodenectomy can be managed by nonoperative or operative interventions. The aim of this study was to analyze the shift in management of five major complications and their success rates. An algorithm was developed according to predictors for type of intervention and failure of management. Methods From 1992–2012, patients with pancreaticojejunostomy, hepaticojejunostomy or gastroenterostomy leakage, postpancreatectomy hemorrhage, or primary abscess after pancreatoduodenectomy were selected from a prospectively maintained database. Complications were treated by nonoperative or operative intervention Two cohorts were created according to period of index operation. Pre- and postoperative characteristics were analyzed. Results Of 1,037 patients, 263 (25%) experienced operative complications. The incidence of pancreatic fistula increased from 11 to 18%, accompanied by a shift from operative toward nonoperative management. This was also seen in the management of late hemorrhage. Success rates of interventions remained similar for all complications. The incidence of primary abscesses decreased. Early sepsis (odds ratio [OR] 17.8, 95% confidence interval [CI] 4.9–64.4) was associated with failure of nonoperative interventions in patients with pancreatic fistula. Hemodynamic instability (OR 17.2, 95% CI 1.8–160.1) and sepsis (OR 6.7, 95% CI 2.7–16.3) were predictive for operative intervention. Failure of nonoperative intervention (HR 3.95% CI 1.3–7.1) and operative intervention (HR 6.4 95% CI 3.2–12.8) were predictors for poor survival. Conclusion The shift towards nonoperative interventions was notable in patients suffering from pancreaticojejunostomy leakage and late hemorrhage. Anastomotic leakage, late hemorrhage, and primary abscesses can be managed nonoperatively however; hemodynamic instability and early sepsis are strong arguments to perform surgery.
    Surgery 09/2014; DOI:10.1016/j.surg.2014.04.026 · 3.11 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Postoperative pancreatic fistula (POPF) is the leading complication after partial pancreatic resection and is associated with increased length of hospital stay and resource utilization. The introduction of a common definition in 2005 by the International Study Group of Pancreatic Surgery (ISGPS), which has been since employed in the vast majority of reports, has allowed a reliable comparison of surgical results. Despite the systematic investigation of risk factors and of surgical techniques, the incidence of POPF did not change in recent years, whereas the associated mortality has decreased.
    Langenbeck s Archives of Surgery 08/2014; 399(7). DOI:10.1007/s00423-014-1242-2 · 2.16 Impact Factor