Post-pancreaticoduodenectomy hemorrhage:risk factors, managements and outcomes

BACKGROUND： Post-pancreaticoduodenectomy（PD） hemorrhage（PPH） is an uncommon but serious complication. This retrospective study analyzed the risk factors, managements and outcomes of the patients with PPH.METHODS： A total of 840 patients with PD between 2000 and2010 were retrospectively analyzed. Among them, 73 patients had PPH： 19 patients had early PPH and 54 had late PPH.The assessment included the preoperative history of disease,pancreatic status and surgical techniques. Other postoperative complications were also evaluated.RESULTS： The incidence of PPH was 8.7%（73/840）. There were no independent risk factors for early PPH. Male gender（OR=4.40, P0.02）, diameter of pancreatic duct（OR=0.64,P0.01）, end-to-side invagination pancreaticojejunostomy（OR=5.65, P0.01）, pancreatic fistula（OR=2.33, P0.04）and intra-abdominal abscess（OR=12.19, P0.01） were the independent risk factors for late PPH. Four patients with early PPH received conservative treatment and 12 were treated surgically. As for patients with late PPH, the success rate of medical therapy was 27.8%（15/54）. Initial endoscopy was operated in 12 patients（22.2%）, initial angiography in 19（35.2%）,and relaparotomy in 15（27.8%）. Eventually, PPH resulted in 19 deaths. The main causes of death were multiple organ failure,hemorrhagic shock, sepsis and uncontrolled rebleeding.CONCLUSIONS： Careful and ongoing observation of hemorrhagic signs, especially within the first 24 hours after PD or within the course of pancreatic fistula or intra-abdominal abscess, is recommended for patients with PD and a prompt management is necessary. Although endoscopy and angiography are the standard procedures for the management of PPH,surgical approach is still irreplaceable. Aggressive prevention of hemorrhagic shock and re-hemorrhage is the key to treat PPH.

Angiosarcomatous component in gliosarcoma: case report and consideration of diagnostic challenge and hemorrhagic propensity

An angiosarcomatous component in gliosarcoma may be associated with an increased intraoperative hemorrhagic risk and preoperative diagnostic challenge. We report a unique case of gliosarcoma with an angiosarcomatous component in a 61-year-old man. His brain MRI demonstrated a well-demarcated right occipital tumor with multiple flow voids and rim-like enhancement as well as intratumoral strip and nodular enhancements. He underwent a craniotomy for tumor resection. Intraoperatively, significant tumor hemorrhage required greater efforts to control intraoperative bleeding and to maintain hemostasis. Pathological examination of the tumor revealed alternating gliomatous and sarcomatous/angiosarcomatous components with intratumoral hemorrhage. He was postoperatively treated with chemoradiation. The tumor recurred at 9 months, for which the second resection was performed with similarly greater efforts to achieve hemostasis. The recurrent tumor was pathologically similar despite treatment-associated changes. Awareness of this angiosarcomatous component in gliosarcoma with the hemorrhagic risk is important for both the preoperative diagnosis and surgical management.

Vitreous haemorrhage:a population-based study of the incidence and risk factors in Taiwan

AIM：To report the epidemiology and incidence of vitreous hemorrhage and to evaluate risk factors for patients with vitreous hemorrhage（VH）in Taiwan.METHODS：A retrospective population-based study.Analyzing a sample of one million subjects from all enrollees of the Taiwan Health Insurance programme. All data were obtained from the Taiwan Health Insurance Research Database,which contained patient sex,date of birth,all records of clinical visits and hospitalizations,and diagnosis codes as included in the International Classification of Diseases,Ninth Revision,Clinical Modification（ICD-9-CM）. The main outcome measures were the incidence and risk factors of VH.RESULTS：From 2001 to 2010,the database claim 4379 newly diagnosed cases were identified with VH. The average incidence of VH in Taiwan was 4.8 cases per ten-thousand person-years generally and increased with time especially in subjects who aged between 40 and 59 y and when the VH was associated with proliferative diabetic retinopathies or retinal vein occlusions. A de-finitely upward trends in the incidence of VH from 2001 to 2010 were noted（P-value for increasing trend 〈0.001）. Univariate Cox＇s regression analysis pointed out that older age（for 40-59,P〈0.001,HR=9.39; for ≥60,P〈0.001,HR=11.39）,male gender（P=0.03,HR=1.07）and subjects who had been prescribed anti-coagulation drug included aspirin,warfarinand clopidogrel（P〈0.001,HR=2.20）were significant risk factors for suffering from VH.CONCLUSION：The incidence of VH is estimated being 4.8 cases per 10 000 person-years in Taiwan. Age,male gender and having been prescribed anti-coagulation drugs are associated with the incidence of VH.