Risk Factors,diagnosis And Treatment Of Hemorrhage After Pancreatoduodenectomy

Objective To explore the risk factors,diagnosis and treatment strategies of postpancreatoduodenectomy hemorrhage(PPH).Methods The clinical data of 424 patients who underwent pancreatoduodenectomy(PD)during Jan.1,2005 and Dec.31,2017 were retrospectively analyzed to evaluate the risk factors,diagnosis and treatment strategies of the occurrence of PPH,and the potential related risk factors including sex,age,diabetes,hypertension,duration of jaundice,preoperative hemoglobin level,preoperative albumin level,preoperative total bilirubin level,preoperative biliary drainage,operative time,the way of pancreaticojejunostomy,the way of pancreatic duct drainage,placement of T tube or not,blood loss,blood transfusion or not,postoperative pancreatic fistula,postoperative biliary fistula,abdominal infection.The potential clinical factors that may affect PPH were analyzed by chi-square test,and then the factors with statistical significance were selected and were analyzed by multivariate logistic regressionanalysis,to explore the risk factors,diagnosis and treatment strategies of PPH.Results Child was used to reconstruct the digestive tract in all the 424 cases of PD.There were 215 patients received end-to-end pancreaticojejunostomy,122 patients received mucosa-to-mucosa pancreaticojejunostomy,83 patients received binding pancreaticojejunostomy,4 patients was not performed any pancreaticojejunostomy because of total pancreatectomy.All of the patients received end-to-side choledochojejunostomy and side-to-side or end-to-side gastrojejunostomy(except for 2 patients received pylorus-preserving gastrojejunostomy).PPH occurred in 60 patients,9 of whom died,and the mortality was 2.12%(9/424).Of these 9 patients,6 died due to hemorrhage.Early hemorrhage(?24 h after operation)were detected in 14 patients and the delayed hemorrhage(>24 h after operation)in 46 patients;intra-abdominal hemorrhage occurred in 23 cases,gastrointestinal hemorrhage occurred in 14 cases,intra-abdominal hemorrhage + gastrointestinal hemorrhage occurred in 3 cases,and the site of hemorrhage were not found in 2 cases;3,22 and 35 patients with PPH were classified as grade A,B,C,respectively;there were 40 cases of sentinel bleeding and 4 cases of pseudoaneurysm.Among 14 patients with early hemorrhage,8 patients received hemostasis under emergency exploratory laparotomy,2 patients received hemostasis under gastroscopic hemostasis,and 4 patients received only conservative treatment;Among 46 patients with delayed hemorrhage,emergency exploratory laparotomy was performed in 5 cases,gastroscopy in 14 cases,digital subtraction angiography in 8 cases,and only conservative treatment in 24 cases.Univariate analysis showed that complications such as hypertension,pancreatic fistula,biliary fistula,and intra-abdominal infection were related risk factors of PPH(?2=7.832.,28.491,7.086,25.378,respectively,P<0.05),and other potential related risk factors such as sex,age,diabetes,duration of jaundice,preoperative hemoglobin level,preoperative albumin level,preoperative total bilirubin level,preoperative biliary drainage,operative time,the way of pancreaticojejunostomy,the way of pancreatic duct drainage,placement of T tube or not,blood loss,blood transfusion or not were not statistically significant.Logistic multivariate analysis hypertension,intra-abdominal infection and pancreatic fistula were independent risk factors of PPH(OR=2.242,3.068,2.953,respectively,95%CI=1.169?4.300,1.501?6.274.,1.491?5.849,respectively,P<0.05).Conclusion Complicated hypertension,pancreatic fistula,and intra-abdominal infection are the independent risk factors of PPH.The keys to prevent PPH are to maintain stable blood pressure,reduce pancreatic fistula and intra-abdominal infection perioperatively.At the same time,we should pay attention to the predictive effect of sentinel bleeding and the prevention and treatment of trauma induced coagulopathy.In case of PPH,the choice of diagnosis and treatment strategies should be determined according to the onset,location and severity of hemorrhage.Most of the patients with early haemorrhage needs emergency exploratory laparotomy and most of the patients with delayed hemorrhage can be cured by conservative treatment.