Vascular Complications of Pancreaticoduodenal Resection: Prevention and Treatment

Abstract

Objective. Analysis of early and late vascular complications (thrombosis, bleeding), their causes, and treatment strategies in patients after pancreaticoduodenal resection (PDR), including vascular reconstruction.

Materials and Methods. A retrospective analysis was conducted on the technical aspects of the operation and the postoperative period of 595 patients who underwent pancreaticoduodenal resection between 2006 and 2020. Resection of major vessels was performed in 180 (30.3%) patients. The origin, quantity, and severity of postoperative complications were evaluated.

Vascular complications were classified as intra-abdominal bleeding or thrombosis of major vessels diagnosed within the first 24 hours after surgery. Late complications, usually erosive in origin, referred to intra-abdominal bleeding occurring more than 24 hours after surgical treatment.

Pancreaticoenteric anastomotic leakage was defined as a type B or C pancreatic fistula according to the recommendations of the International Study Group of Pancreatic Fistula (ISGPF) in 2016.

Mortality was considered as an lethal outcome within 30 days or during the hospitalization period.

Results. Reconstruction of major venous collectors during pancreaticoduodenal resection (PDR) was performed as a standard option in 180 out of 595 patients, accounting for 30.3% of cases.

Thrombosis of the reconstructed area was detected in 17 patients (9.4%). Early thrombosis occurred in 10 patients (5.6%). Diagnosed early venous thrombosis presented with bright clinical symptoms, allowing for timely detection. Active surgical tactics successfully performed thrombectomy in three patients, leading to recovery. In two patients, reconstruction was unsuccessful, including one case due to significant portal hypertension in the presence of chemotherapy-related hepatosis. Conservative treatment was unsuccessful in five patients. Lethal outcomes occurred in seven cases where failed to restore blood flow through the portal vein.

Apparently, some early thromboses did not manifest clinically and remained undiagnosed, just as late thromboses of major vessels after reconstruction were usually asymptomatic and were diagnostic findings in seven patients.

Intra-abdominal bleeding within the first 24 hours was diagnosed and successfully controlled in three patients (0.5%).

Late fatal erosive bleeding developed in 17 patients (30.1%) out of 55 patients with pancreatic fistula. Treatment for erosive bleeding was largely ineffective, with the primary focus on preventing the formation of pancreatic fistula.

All patients diagnosed with pancreatic fistula were divided into two treatment groups (Group 1 - 296 patients, Group 2 - 299 patients). The differences in the treatment approach for pancreatic fistula were related to the application of active aspiration of the fistula in the second group of patients. The patient groups did not have significant demographic or operative differences.

In the first group, without active aspiration, the number of class B fistulas was 8 (2.7%) and class C fistulas were 26 (8.8%). In the second group, the number of class B fistulas was 9 (3%), while the number of severe class C fistulas significantly decreased to 12 (4%) (p= 1, χ² - 0.051 and p= 0.027, χ² - 4.892, respectively). In the first group, the number of late bleeding events was 14 (4.7%), compared to 3 (1%) in the second group (p= 0,006, Хи2 – 7,442).

Overall mortality in the groups decreased from 5.7% to 1.7% (the difference was statistically significant, p= 0.016, χ² - 5.827).

Conclusion.

Resections and reconstructions of major portal venous vessels during pancreaticoduodenal resection (PDR) were performed in 30.3% of patients. We have identified early and late vascular complications (thrombosis and bleeding), which allows for a clear determination of their treatment strategy.

Among the diagnosed 17 thromboses out of 180 reconstructions of major veins, early symptomatic thrombosis occurred in 10 patients (5.6%). The most effective approach was successful emergency (within 12 hours) revascularization, which was performed in 3 patients. Two unsuccessful thrombectomies and conservative treatment in 5 patients led to fatal outcomes. Asymptomatic thrombosis in 7 patients was detected during follow-up examinations.

The proportion of early intra-abdominal bleeding was insignificant (0.5%) and usually associated with pre-existing coagulopathy. Late erosive bleeding was diagnosed in 17 patients as a result of pancreatic fistula. Surgical control of bleeding was effective in 3 patients.

The prevention and active treatment of pancreatic fistula significantly reduced their number and, consequently, the frequency of bleeding events from 14 (4.7%) in the first group to 3 (1%) in the second group with an active treatment approach. As a result, the mortality rate decreased from 5.7% to 1.7%.

The proposed protocol for preventing and treating vascular complications in patients who have undergone PDR has shown its effectiveness. In cases of pancreaticoenteric anastomotic failure, it is advisable to use active aspiration to prevent erosive bleeding. For the prevention of late erosive bleeding, after successful treatment of surgical complications, it is recommended to perform contrast-enhanced computed tomography of the abdominal cavity 20-30 days after the last surgical intervention to detect aneurysmal dilatations of visceral arteries.