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: 2.68).
12/2012; 14(12):812-7. DOI: 10.1111/j.1477-2574.2012.00545.x
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.
Available from: Waldemar Uhl
- "No patient with interventional drainage required relaparotomy and no procedure associated complications occurred . Thus, the initial management of late bile leaks should be conservative, patients with biliary peritonitis require relaparotomy, while massive delayed visceral hemorrhage remains the most threatening postoperative complication  . "
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After pancreatectomy, an isolated bile leak from the hepaticojejunostomy is a severe surgical complication that is underrepresented both, in the literature and in the awareness of pancreatic surgeons. The goal of this study was to analyze the incidence and outcome of isolated bile leaks after pancreatectomy.
Material and methods:
A retrospective study of patients who underwent duodenopancreatectomy or total pancreatectomy at a single-center institution was performed, which analyzed incidence and course of patients with postoperative bile leaks from the hepaticojejunostomy.
During a period of 42 months, 209 patients underwent pancreatic head resection or total pancreatectomy. Bile leaks occurred in 4% (8/209) and were more common in patients with distal bile duct cancer. Bile leaks led to longer hospital stay and were associated with abscess formation and other infectious complications. Unlike expected, most postoperative bile leaks occurred in the late postoperative period. Three patients required relaparotomy for biliary peritonitis or delayed visceral hemorrhage, while the other five patients underwent conservative management, including CT drainage and antibiotic therapy. One patient with a postoperative bile leak died due to delayed visceral hemorrhage.
In contrast to recently published data, isolated postoperative bile leaks after pancreatectomy often occur in the late postoperative period and more frequently require a relaparotomy than the literature suggests. The presented study results may sensitize surgeons for this often disregarded topic and activate the discussion on treatment options.
Available from: Lionel Rebibo
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ABSTRACT: Despite improvements in surgical techniques and postoperative care, morbidity associated with pancreatoduodenectomy (PD) is still high. Grade B pancreatic fistula (PF) requires a specific combination of radiologically guided external drainage and medical support. This treatment is effective but requires prolonged hospitalization and maintenance of external drainage. The objective of this study was to evaluate the feasibility and efficacy of a double-pigtail stent (DPS) to treat grade B PF after PD with pancreatogastric anastomosis.
Between January 2008 and October 2011, all patients who presented grade B PF after PD (n = 6) were included in the study. The PF was diagnosed according to the criteria of the International Study Group on Pancreatic Fistula. Endoscopic treatment was standardized with a DPS. The primary efficacy end point was the feasibility and efficacy of DPS placement. Secondary end points included data on the PF, the DPS placement procedure, and long-term outcome.
Endoscopic DPS placement was achieved in all patients with no complications. The median time to onset of PF after PD was 14 days. Closure of the external PF was obtained 7 days after the introduction of the DPS. The median time to external drain removal was 7 days after DPS placement, and the median time to oral refeeding was 7 days after DPS placement for all patients. The median time to DPS removal was 60 days. The median length of hospital stay after DPS placement was 10 days. During a median follow-up period of 21 months, there was no recurrence of PF after removal of the DPS.
Endoscopic treatment of grade B PF after PD appears to be effective and safe and is associated with shorter hospitalization.
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