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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1143_Библиотеки_им_академика_М_И_Перельмана
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Fig. 40.1 US showing a
dilated CBD of 2 cm
Fig. 40.2 ERCP and
sphincterotomy, stop distal
CBD, placement of a stent
M.A. Cuesta and S.S. Gisbertz
Operation
CT scan and MRI enteroclysis showed a huge polypoid mass in duodenum and in
the small bowel and colon (Figs. 40.3 and 40.4 ). Policy was executed as treating the
multiple polyps in steps, starting with the duodenum. Two attempts were undertaken for resecting the huge polyps by duodenoscopy, but this was considered
40 Case on Postoperative Bleeding After Whipple Procedure
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Fig. 40.3 CT scan, mass in
duodenum with stent in the
CBD
Fig. 40.4 MRI enteroclysis,
polyps in jejunum and ileum
221
unfeasible. Despite a benign histological examination, the possibility of malignancy
was considered and a transduodenal polypectomy or a Whipple procedure by laparotomy was decided on. Through subcostal laparotomy, locally resecting the huge
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Fig. 40.5 Duodenum aspect
during Whipple operation
M.A. Cuesta and S.S. Gisbertz
tumor was considered unachievable without Whipple operation (Fig. 40.5 ). A duo-
denopancreatectomy was performed without technical problems and after operation
patient was admitted to the general ward.
Postoperative Course: Identifi cation and Treatment
of the Complication
Two hours later, the patient started with hematemesis and become hemodynamically unstable. The on duty surgeon decided to reoperate directly due to abundant
bleeding and hemodynamic instability. At laparotomy, a dilated gastric remnant was
found with dilatation of the loop to the pancreas as produced by clots. The anastomosis to the pancreas was performed end to side and we opened the end loop of the
anastomosis in order to inspect fi rst the pancreaticojejunostomy. There was bleeding at the capsule of the pancreas, and we could fi x it by means of stitches. The
opening was closed in transversal direction in two layers and the stomach emptied
of clots.
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223
Pathology
Pathology examination of the specimen showed benign polyps typical for Peutz Jegher
syndrome. Patient recovered well after this reoperation and 6 months later he was
again operated to remove the small bowel polyps, endoscopically assisted by the gastroenterologist. All polyps were proven to be benign and patient is doing well. The rest
of the colon polyps will be resected by colonoscopy program. The patient has no progeny but a genetic study has been performed regarding himself and family members.
Second Patient
Postoperative Intraabdominal Bleeding After Whipple
Procedure
Diagnosis and Indication for Surgery
A 69-year-old female patient was evaluated because of silent obstruction jaundice.
She had a pancreatic head tumor with double duct lesion suspect for carcinoma and
because of a bilirubin less than 150 U/ml, a direct surgical exploration was carried
out without previous drainage of the biliary duct.
Operation
A Whipple operation was performed without technical problems and the blood loss
was 300 cc.
Postoperative Course: Identifi cation and Treatment
of the Complication
She went to the Medium Care Department and after a couple of hours, her blood
pressure decreased to 70/40 mm Hg and her hemoglobin and hematocrit decreased
2 points to 5 and 23 % respectively. Coagulation tests were normal.
Her abdomen was painful and lightly distended and clots occluded the left drain.
After diagnosis of postoperative bleeding, a relaparotomy through the subcostal
incision was again performed.
Especially in the subhepatic space, 1.5 L blood with clots were found. Inspection
showed two venous bleeding points along the portal vein. These were sutured with
care in order to maintain the pancreatic and biliary anastomosis without any changes.
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A new drain was left in the subhepatic space and patient recovered without
complications.
M.A. Cuesta and S.S. Gisbertz
Comments
The lesson in these two patients with immediate postoperative bleeding after a
Whipple procedure and hemodynamically instability is that an emergency relaparotomy can fi x the problem. Important is that the same surgeon who did the operation will perform the reoperation.
Discussion
Postoperative hemorrhage is another serious complication after pancreatic resection
with incidence rates varying from 2 to 20 % and mortality rates exceeding 50 %
[ 1 – 3 ]. The variability in incidence and mortality is partly caused by the many differ-
ent defi nitions that are being used. The International Study Group of Pancreatic
Surgery (ISGPS) developed a defi nition and proposed the term postpancreatectomy
hemorrhage (PPH) [ 2 ]. They classifi ed postoperative bleeding based on three crite-
ria: time of onset: early PPH occurring within 24 h postoperatively and late PPH
>24 h; location: intraluminal or extraluminal; and severity and impact: mild PPH
with a similar clinical impairment and severe PPH with sequential blood transfusions and radiological and/or surgical interventions.
Since the introduction of the ISGPS hemorrhage classifi cation, a number of studies validated the scoring system which is currently generally accepted [ 3 , 4 ].
Diagnosis and grading. Patients who develop PPH may present with hypotension, tachycardia, decreasing haemoglobin concentration, clinical deterioration, or
blood loss through gastrointestinal tract or abdominal drains depending on the site
of the bleeding: intraluminal or extraluminal.
Intraluminal bleeding is seen near the anastomotic site, vessels in that area, the
surface of the pancreas, or near a gastric ulcus. It generally presents with blood loss
through the gastrointestinal tract being hematemesis and melena and blood loss
through the nasogastric tube. Intraluminal bleeding will usually manifest as an early
hemorrhage. Consensus has been reached considering the cause of early hemorrhage which is likely due to technical failures during the index operation. In the case
of intraluminal hemorrhage, endoscopy can be very useful since diagnosing and
managing an anastomotic bleeding can be performed simultaneously. Angiography
can be used to embolize bleeding from vessels. A recent analysis showed that angiography was performed in over 50 % of patients with PPH after pancreatic surgery
and 18 % was subjected to an endoscopy. Both procedures were initially performed
to detect the bleeding site [
that the patient was in a stable hemodynamic condition.
5 ]. All diagnostic interventions were performed provided
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Extraluminal bleeding is seen in the abdominal cavity and may be evident by
blood loss through the abdominal drain. The bleeding is caused by vascular erosion,
anastomotic ulceration, arterial pseudoaneurysm, or disrupted suture-line caused by
POPF, biliary leakage, or intra-abdominal infections and generally present as late
PPH. When PPH is suspected, ultrasonography and CT can detect intra-abdominal
collections (hematoma as well as abscesses) seen in 70–80 % in late PPH.
Furthermore, both procedures can detect pseudoaneurysms. The diagnosis is confi rmed by angiography [ 6 ].
225
Management and Outcome
Severe PPH asks for immediate treatment through either radiological intervention,
e.g. angiography with embolisation or endoscopy with clips or sclerotherapy, or
surgical intervention when the patients’ condition is deteriorating rapidly or radiological interventions are unsuccessful or infeasible.
In a recent study on PPH 38 % of patients underwent primary surgery, 57 %
underwent primary radiological intervention and 5 % was treated conservatively.
More than half of the radiological interventions (54 %) were unsuccessful and a
rescue laparotomy still had to be performed. The success rate of radiological coiling
in terms of hemostasis was 80 % [ 5 ]. In this study endoscopic intervention was used
in patients with early intraluminal bleeding realizing that a PJ bleeding generally is
outside the reach of endoscopy but can also be managed by interventional angiography. Intraluminal bleeding can disrupt the anastomosis causing a “false” extraluminal bleed since blood is than seen in the abdominal cavity. Early extraluminal
PPH (within 24 h after surgery) is generally managed immediately with
relaparotomy.
Management of late PPH is different since it is often caused by pseudoaneurysms due to POPF or intra-abdominal infections. An earlier study conducted at the
AMC showed that 69 % of patients with late PPH underwent primary surgery and
only 9 % was managed by radiological embolisation. In half of all the surgical procedures a vessel ligation was performed. Completion pancreatectomy was performed because of persistent anastomotic leakage [ 6 ].
More recently embolisation is performed in the majority of patients.
A meta-analysis regarding the management of late PPH after PD showed 20
small case series with 163 patients in which 47.2 % of patients underwent primary
surgery, 44.8 % underwent primary radiological intervention and 8 % was treated
conservatively. No signifi cant differences were found regarding to morbidity or
mortality between relaparotomy and radiological intervention. Though late
haemorrhage is often already associated with other complications, in particular
leakage and sepsis, as mentioned earlier this combination is associated with a poor
prognosis [ 7 ].
The pathophysiology of early PPH makes its management less complicated with
better outcomes compared to late PPH. Identifying the importance of a sentinel
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M.A. Cuesta and S.S. Gisbertz
bleed and an adequate aggressive approach towards the patients’ clinical status will
dictate the appropriate treatment. More research is needed to offer any standardized
rules in the management of PPH.
References
1. Tol JAMG, van Gulik TM, Busch ORC, Gouma DJ. Prevention and treatment of major compli-
cations after duodeno-pancreatic head surgery. In: Cuesta MA, Bonjer HJ, editors. Treatment
of complications after digestive surgery, chapter 14. London: Springer; 2013.
2. Wente MN, Veit JA, Bassi C, Dervenis C, et al. Postpancreatectomy hemorrhage (PPH): an
International Study Group of Pancreatic Surgery (ISGPS) defi nition. Surgery. 2007;142:20–5.
3. Jagad RB, Koshariya M, Kawamoto J, et al. Postoperative hemorrhage after major pancreato-
biliary surgery: an update. Hepatogastroenterology. 2008;55:729–37.
4. Puppala S, Patel J, McPherson S, et al. Hemorrhagic complications after Whipple surgery:
imaging and radiologic intervention. AJR Am J Roentgenol. 2011;196:192–7.
5. Yekebas EF, Wolfram L, Cataldegirmen G, et al. Postpancreatectomy hemorrhage: diagnosis
and treatment: an analysis in 1669 consecutive pancreatic resections. Ann Surg.
2007;246:269–80.
6. de Castro SM, Kuhlmann KF, Busch OR, et al. Delayed massive hemorrhage after pancreatic
and biliary surgery: embolization or surgery? Ann Surg. 2005;241:85–91.
7. Limongelli P, Khorsandi SE, Pai M, et al. Management of delayed postoperative hemorrhage
after pancreaticoduodenectomy: a meta-analysis. Arch Surg. 2008;143:1001–7.
Chapter 41
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Case on Leakage of the PancreatoJejunostomy After a Whipple Procedure
Suzanne S. Gisbertz
Keywords Leakage • Pancreato-jejunostomy • Whipple • Duodenopancreatectomy
• Leakage pancreatojejunostomy
Diagnosis and Indication for Surgery
A 72-year-old female patient was analyzed for silent jaundice and itchiness since 3
weeks. Her medical history revealed surgery for kidney stones and spinal disc hernia, hypertension, and dyslipidaemia, for which she used medication. Physical
examination showed jaundice, scratch effects on the skin, and a palpable, nontender gallbladder (Courvoisier’s sign). Laboratory testing showed elevated levels
of bilirubin, AF, and g-GT. Ultrasound, CT scan, and endoscopic ultrasound showed
a double duct sign, with both dilated bile and pancreatic ducts. No masses or
enlarged lymph nodes were identifi ed. ERCP showed a normal papilla Vateri, and a
distal obstruction was observed in the common bile duct. Because of high bilirubin
rate >150 U/ml, a sphincterotomy was performed, followed by introduction of an
endoprosthesis in order to drain the biliary duct before operation. Since no metastases were identifi ed, this patient was scheduled for a Whipple procedure.
Operation
A duodenopancreatectomy according to Whi pple was performed, with and an endside pancreaticojejunostomy, an end-side hepaticojejunostomy, and an end-side
gastrojejunostomy. A low vacuum drain was placed at the anastomotic sides.
S. S. Gisbertz , M.D.
Department of Surgery , Academic Medical centre , Amsterdam , The Netherlands
e-mail: s.gisbertz@antoniusziekenhuis.nl
M.A. Cuesta, H.J. Bonjer (eds.), Case Studies of Postoperative Complications
after Digestive Surgery, DOI 10.1007/978-3-319-01613-9_41,
© Springer International Publishing Switzerland 2014
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S.S. Gisbertz
Pathology
The surgical resection specimen showed a radical resected well-differentiated ductal adenocarcinoma with a maximum diameter of 2.8 cm. No lymph node metastases were identifi ed. Therefore, the TNM classifi cation was pT3N0M0.
Postoperative Course: Identifi cation and Treatment
of the Complication
The fi rst 5 postoperative days were uneventful. On the 6th postoperative day, the
patient clinically deteriorated. She developed abdominal pain, fever, and a tachycardia. Laboratory research showed a leukocytosis and elevated levels of C-reactive
protein. An abdominal CT scan showed free fl uid around the anastomoses and both
left and right paracolic (Fig. 41.1a–c ). A percutaneous drain was placed in the right
paracolic space. The aspect was serous, and the amylase level was low (135 U/L).
Additionally, broad-spectrum antibiotics were given intravenously and adjusted after
positive cultures. Despite this treatment, the patient did not recover, and on the 10th,
13th, and 18th day, additional percutaneous drainages were performed subhepatic
(amylase 9,503 U/L), left subfrenic and in the right lower quadrant (amylase
290 U/L), and left paracolic (amylase level not determined), respectively. Furthermore,
a percutaneous transhepatic cholangiography (PTC) was performed on the 18th postoperative day, with the tip of the catheter through the hepaticojejunostomy (Figs. 41.2 ,
41.3 and Illustration 41.1 ). On the 24th day, the amylase drain fl uid level reached its
peak of 21,998 U/L. The fi rst cultures of the drain fl uids notably showed the same
bacteria as on the peroperative bile culture: enterococcus species and Candida albi-
cans . On the 27th day, blood was suddenly observed at the subhepatic drain. A
CT-angiography and angiography did not show the source of bleeding and the problem spontaneously resolved. The patient remained hemodynamically stable throughout this episode. Slowly she could recover and regain strength with the aid of physical
therapy and nutritional support. Eventually, she was discharged without any drains
on the 49th postoperative day. Subsequently, she was readmitted twice with abdominal pain and fever based on an intra-abdominal abscess, treated with percutaneous
drainage. On her last outpatient visit, 10 months after the initial operation, she displayed no symptoms of disease and no signs of recurrence. She regained her old
weight, did not develop diabetes, but she does use pancreatic enzyme supplements.
Discussion
This patient with leakage from the pancreaticojejunostomy was treated with multiple percutaneous drainages, PTC, and antibiotics, without the need for surgical
reintervention.
41 Case on Leakage of the Pancreato-Jejunostomy After a Whipple Procedure
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a
b
c
229
Fig. 41.1 ( a ) CT scan, Leakage of the pancreaticojejunostomy. ( b ) CT scan, Intra-abdominal free
fl uid. ( c ) CT scan, free fl uid in the right paracolic space
Fig. 41.2 Two percutaneous
drains: a PTC drain and a
subhepatic drain
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