Postoperative hemorrhage complications after the Whipple procedure

Abstract

Case Series Turk J Surg 2018 DOI: 10.5152/turkjsurg.2017.3758 Cite this paper as: Dilek ON, Özşay O, Acar T, Gür EÖ, Çelik SC, Cengiz F, Cin N, Hacıyanlı M. Postoperative hemorrhage complications after the Whipple procedure. Turk J Surg 2018; DOI: 10.5152/ turkjsurg.2017.3758 is stopped if any hemorrhage is suspected. Angiography and embolization can be performed in daytime cases. RESULTS A total of 185 pancreticoduodenectomy surgeries, including 165 classical Whipple procedures and 20 pylorus-preserving surgeries, were performed in our hospital in the last five years (2011 to 2015) due to periampullary region tumors. Three of the patients were female, and 10 were male. The mean age was 61.6 years (ages 42 to 72). It was found that in 13 (7%) of the patients who underwent operations, a procedure was performed due to hemorrhage. Among the patients who had follow-ups due to hemorrhages, nine (77%) underwent surgeries and six (46%) died in the early period (Table 1). In our series, pancreatic fistula was detected in 46 (24.8%) patients, and 6 (13%) of these patients had complications of hemorrhage due to fistulas. It was also found that endoscopic retrograde cholangiopancreaticography (ERCP) was performed diagnostically in nine patients, a stent was placed to lower billirubin levels in six patients, and a drain was placed with percutaneous transhepatic cholangiography in two patients. In seven patients in our series, there was a combination of wide duct (4 to 7 mm) and soft pancreatic texture; the presence of fistula was detected in three of these patients as a cause of hemorrhage. In three of our cases, soft pancreatic texture and the presence of a 2 mm duct were detected. In three of our cases, normal pancreatic tissue was detected; the duct widths ranged from 2 to 5 mm (Table 1). Among our patients with hemorrhage, three of the five patients whose billirubin levels were high (direct bilirubin, range: 10.6 to 21.6 mg/dL) died as a result of hemorrhage complications. Another result we found in our patients is that serum protein levels were normal in three patients and below normal in the remaining patients. Platelet count was higher than normal in five of our patients and was normal in the remaining patients. In cases who did not develop fistulas, C-reactive protein (CRP) levels were within normal limits in the preoperative period, increased in the postoperative early period, and decreased progressively. In all the cases who developed fistula and anastomotic leakage, CRP levels continued to increase until clinical recovery was obtained. In general, it was found that in our patients who developed fistulas and had high CRP levels, blood calcium levels decreased and remained below normal. Of our two cases who developed hemorrhage in the early postoperative period, one underwent surgery due to hemorrhage from the gastric anastomosis (nasogastric tube) and the other underwent surgery due to hemorrhage from the branches of the mesenteric vein (drain); both were discharged with complete healing. Six of our patients were found to bleed from the portal vein (three cases), gastroduodenal artery (two cases), meso veins, and pancreatic artery (one case) due to fistulas at variable periods. Hemorrhage from the portal vein after fistula was seen on the postoperative 8th, 15th, and 27th days; two of these patients died after surgery (Table 1). In one of the cases that was on follow-up due to a fistula and bleeding from the nasogastric tube, an anastomotic leakage was detected by endoscopy. The patient was taken into surgery on the postoperative 15th day; however, the patient died from a hemorrhage that was found to be due to erosion from the portal vein. In another patient who had blood coming out of the Dilek et al. Whipple procedure and hemorrhage Table 1. Patient characteristics Patient Age/ Indication for ISPG Onset of no Sex Whipple/PD Etiology Bleeding site group bleeding Procedure Outcome 1. 58/M Bile duct tumor PO arrest-CPR-sepsis DIC C Day 5 ICU Died 2. 65/M Pancreatic carcinoma PJ hematoma Pancreatic artery? B Day 4 Primary suture Died 3. 66/M Pancreatic carcinoma Fistula GDA B Day 35 Laparotomy+primary Survived suture+angiography+ embolization 4. 60/M Ampullary cancer LMW heparin Drain+nasogastric sond A Day 14 Cessation of LMW heparin Survived 5. 69/M Ampullary cancer Pancreatic fistula, sepsis DIC C Day 11 ICU Died 6. 42/F Pancreatic carcinoma Inadvertent surgery? GJ anastomosis A Day 1 Laparotomy+gastrotomy+ Died primary suture 7. 65/F Ampullary cancer Pancreatic fistula Portal vein Day 8 Laparotomy+primary suture Survived 8. 74/M Pancreatic carcinoma Pancreatic fistula Portal vein C Day 27 Angiography+laparotomy+ Died primary suture 9. 67/F Pancreatic carcinoma Pancreatic fistula, Traumatic portal C Day 15 Laparotomy+primary suture Died PJ leakage+GJ leakage vein laceration? 10. 65/M Bile duct tumor Pancreatic fistula GDA B Day 7 Angiography+laparotomy+ Survived primary suture 11. 58/M Pancreatic carcinoma Inadvertent surgery? Mesenteric vein branches B Day 2 Laparotomy+primary suture Survived 12. 67/M Ampullary cancer Pancreatic fistula Mesenteric vein C Day 7 Laparotomy+primary suture Died 13. 45/M Pancreatic carcinoma Inadvertent surgery? Mesenteric artery and B Day 1 Laparotomy+primary suture Survived vein branches ISPG: international study group of pancreatectomy; GDA: gastroduodenal artery; PJ: pancreaticojejunostomy; GJ: gastrojejunostomy; PO: postoperative; DIC: disseminated intravascular coagulation; ICU: intensive care unit; PD: pancreaticoduodenectomy drain on the postoperative 7th day, the hepaticojejunostomy and pancreaticojejunostomy were found to be opened, and hemorrhage from the pancreatic artery and branches of the mesenteric vein were found. In two cases, laparotomy was performed on the 2nd and 4th days due to bleeding from the drains; hemorrhages arising from the pancreatic artery and branches of the portal vein were repaired. Two cases were found to have developed disseminated intravascular coagulation (DIC) as a result of sepsis; these patients died. In a patient who had been taking LMWH, bleeding from the drains and nasogastric tube stopped following cessation of the drug. DISCUSSION Hemorrhage after Whipple surgery is a rare but serious complication that increases mortality. In the early period, hemorrhage may develop from technical problems, bleeding/clotting disorders, and factors related to the patient; in the latter periods, hemorrhage emerges as a serious problem during the course of fistula and anastomosis-related problems (1, 2). The hemorrhage incidence in the postoperative period reported in the literature (5% to 16%) was similar to the results of our series (7%). However, some publications report that the hemorrhage risk is higher (16% to 45%) in cases who develop fistulas (1, 4). Our mortality rate in the Whipple series was 8.5%, whereas that in our patients with hemorrhage was 46%. First, a medical approach is preferred for the treatment of hemorrhages. In Grade A patients, a conservative approach is more frequently performed in the foreground, whereas in Grade B and C patients, additional processes are required to identify the localization of the hemorrhage. Nasogastric tube (35%), decrease in hemoglobin level (17%), hemodynamic instability (15%), blood coming out of the drains (11%), and the presence of melena (9%) may be helpful to determine the diagnosis and the source of bleeding (8). The source of bleeding can be determined by computerized tomography (CT) angiography in half of these cases (8). In cases where hemodynamic stability is preserved, the first actions are monitoring the patient’s hemodynamic levels and drains. Darnis et al. (8) stated that in their case series of 285 cases with hemorrhage, the hemorrhages were stopped with a medical approach in 32% of cases; in 68% of cases, intervention (surgical, endoscopic, or embolization) was needed (9). In our series, CT angiography was performed in seven cases; hemorrhage from the portal vein was found in two cases, from the gastroduodenal artery in one case, and from the pancreatic artery in one case. The hemorrhage was stopped by embolization in one of these patients, and the rest underwent surgery. In a Grade A patient in our series, the hemorrhage stopped after conservative treatment and cessation of LMWH. Hemorrhages into the lumen are seen in earlier periods. The most common type is hemorrhage arising from pancreaticojejunal anastomosis. In hemorrhages arising from gastrojejunal anastomosis, both diagnostic and therapeutic procedures may be performed by endoscopists. In a series by Eckardt et al. (10), they stated that the source of the bleeding may be detected and treated endoscopically in one third of hemorrhages arising from gastrojejunostomy. Variable approaches are used for this purpose, such as injection, sclerotherapy, and clip application. It is expressed that the routine use of somatostatin analogs in the postoperative period to both suppress pancreatic secretion and prevent complications due to fistula, particularly bleeding in cases where fistulas developed, reduces morbidity; however, these analogs have no positive effects on mortality (11). However, in some cases, protective effects were reported (3). In our series, we found that the risk of hemorrhage was higher (13%) in patients who developed fistulas. We also use somatostatin analogs routinely in our patients with fistulas. Soft pancreatic texture, thinness of the pancreatic duct, and the presence of fistulas are defined as major risk factors for hemorrhage (8). Tani et al. (12) defined male gender, prolonged surgery, and blood transfusion as independent risk factors. Some studies report that parameters such as prolonged hospital stay, ERCP and stenting, the presence of preoperative jaundice, trauma/resection of the splenic vessels, additional surgical procedures, older age, the presence of intraabdominal infection, and nutritional risk index are