Management of bleeding from pseudoaneurysms following pancreaticoduodenectomy

AIM:To review the clinical course and the management of pseudoaneurysms post-pancreaticoduodenectomy.METHODS: Medical records of 907 patients who underwent pancreaticoduodenectomies from January 1995 to May 2007 were evaluated retrospectively. The clinical course, management strategy, and outcome of ruptured pseudoaneurysms cases were analyzed.RESULTS: Twenty-seven (3.0%) of 907 cases had post-operative hemorrhage from ruptured pseudoan-eurysms. Pancreatic fistula was evident in 12 (44%) cases. Sentinel bleeding appeared in 21 (77.8%) cases. Of the 27 cases, 11 (41%) cases demonstrated bleeding pseudoaneurysm of the ligated gastroduodenal artery, 8 (30%) of the right, proper, common hepatic artery, 2 (7%) of the right gastric artery, and 4 (15%) of the peripancreatic arteries. The remaining two patients died due to sudden-onset massive hemorrhage and pseudoaneurysm rupture was suspected. Emergent operation was performed on 2 cases directly without angiography. Angiography was attempted in 23 cases. Eighteen (78.2%) cases succeeded to hemostasis; the five failed cases were explored. After embolization of the hepatic artery, five cases developed liver abscesses or infarction and a single case of hepatic failure expired. Gastroduodenal artery embolization with common hepatic artery stent insertion was performed to enhance hepatic artery flow in a single case and was successfully controlled.CONCLUSION: Bleeding pseudoaneurysms are among the most serious and fatal complications following pancreaticoduodenectomy. Diagnostic angiography has been preferred over endoscopy and is rapidly becoming the standard therapeutic treatment for bleeding pseudoaneurysms.

Carcinoma of the middle bile duct:Is bile duct segmental resection appropriate?

AIM:To compare survival between bile duct segmental resection(BDSR)and pancreaticoduodenectomy(PD) for treating distal bile duct cancers. METHODS:Retrospective analysis was conducted for 45 patients in a BDSR group and for 149 patients in a PD group. RESULTS:The T-stage(P<0.001),lymph node invasion (P=0.010)and tumor differentiation(P=0.005)were significant prognostic factors in the BDSR group.The 3-and 5-year overall survival rates for the BDSR group and PD group were 51.7%and 36.6%,respectively and 46.0%and 38.1%,respectively(P=0.099).The BDSR group and PD group did not show any significant difference in survival when this was adjusted for the TNM stage.The 3-and 5-year survival rates were: stageⅠa[BDSR(100.0%and 100.0%)vs PD(76.9% and 68.4%)(P=0.226)];stageⅠb[BDSR(55.8% and 32.6%)vs PD(59.3%and 59.3%)(P=0.942)]; stageⅡb[BDSR(19.2%and 19.2%)vs PD(31.9%and 14.2%)(P=0.669)]. CONCLUSION:BDSR can be justified as an alternative radical operation for patients with middle bile duct inselected patients with no adjacent organ invasion and resection margin is negative.