ImportancePostpancreatectomy hemorrhage is an uncommon but highly morbid complication of pancreaticoduodenectomy. Clinical evidence often draws suspicion to the gastroduodenal artery stump, even without a clear source.ObjectiveTo determine the frequency of gastroduodenal artery bleeding compared to other sites and the results of mitigation strategies.Design, Setting, and ParticipantsThis cohort study involved a retrospective analysis of data for consecutive patients who had pancreaticoduodenectomy from 2011 to 2021 at Memorial Sloan Kettering Cancer Center (MSK) and Thomas Jefferson University Hospital (TJUH).ExposuresDemographic, perioperative, and disease-related variables.Main Outcomes and MeasuresThe incidence, location, treatment, and outcomes of primary (initial) and secondary (recurrent) hemorrhage requiring invasive intervention were analyzed. Imaging studies were re-reviewed by interventional radiologists to confirm sites.ResultsInclusion criteria were met by 3040 patients (n = 1761 MSK, n = 1279 TJUH). Patients from both institutions were similar in age (median [IQR] age at MSK, 67 [59-74] years, and at TJUH, 68 [60-75] years) and sex (at MSK, 814 female [46.5%] and 947 male [53.8%], and at TJUH, 623 [48.7%] and 623 male [51.3%]). Primary hemorrhage occurred in 90 patients (3.0%), of which the gastroduodenal artery was the source in 15 (16.7%), unidentified sites in 24 (26.7%), and non–gastroduodenal artery sites in 51 (56.7%). Secondary hemorrhage occurred in 23 patients; in 4 (17.4%), the gastroduodenal artery was the source. Of all hemorrhage events (n = 117), the gastroduodenal artery was the source in 19 (16.2%, 0.63% incidence in all pancreaticoduodenectomies). Gastroduodenal artery hemorrhage was more often associated with soft gland texture (14 [93.3%] vs 41 [62.1%]; P = .02) and later presentation (median [IQR], 21 [15-26] vs 10 days [5-18]; P = .002). Twenty-three patients underwent empirical gastroduodenal artery embolization or stent placement, 7 (30.4%) of whom subsequently experienced secondary hemorrhage. Twenty percent of all gastroduodenal artery embolizations/stents (8/40 patients), including 13% (3/13 patients) of empirical treatments, were associated with significant morbidity (7 hepatic infarction, 4 biliary stricture), with a 90-day mortality rate of 38.5% (n = 5) for patients with these complications vs 7.8% without (n = 6; P = .008). Ninety-day mortality was 12.2% (n = 11) for patients with hemorrhage (3 patients [20%] with primary gastroduodenal vs 8 [10.7%] for all others; P = .38) compared with 2% (n = 59) for patients without hemorrhage.Conclusions and RelevanceIn this study, postpancreatectomy hemorrhage was uncommon and the spectrum was broad, with the gastroduodenal artery responsible for a minority of bleeding events. Empirical gastroduodenal artery embolization/stent without obvious sequelae of recent hemorrhage was associated with significant morbidity and rebleeding and should not be routine practice. Successful treatment of postpancreatectomy hemorrhage requires careful assessment of all potential sources, even after gastroduodenal artery mitigation.

中文翻译：

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胰十二指肠切除术后出血部位及缓解策略


重要性胰腺切除术后出血是胰十二指肠切除术的一种罕见但发病率很高的并发症。即使没有明确的来源，临床证据也经常引起对胃十二指肠动脉残端的怀疑。目的确定与其他部位相比胃十二指肠动脉出血的频率以及缓解策略的结果。设计、设置和参与者本队列研究涉及数据的回顾性分析2011 年至 2021 年在纪念斯隆凯特琳癌症中心 (MSK) 和托马斯杰斐逊大学医院 (TJUH) 连续接受胰十二指肠切除术的患者。暴露人口统计学、围手术期和疾病相关变量。主要结果和措施发病率、地点、治疗和结果分析了需要侵入性干预的原发性（初次）和继发性（复发性）出血的情况。介入放射科医生重新审查影像学研究以确认部位。结果 3040 名患者符合纳入标准（n = 1761 MSK，n = 1279 TJUH）。两个机构的患者年龄相似（MSK 斯隆的中位 [IQR] 年龄为 67 [59-74] 岁，TJUH 为 68 [60-75] 岁）和性别（MSK 814 名女性 [46.5%] 和947 名男性 [53.8%]，TJUH 623 名男性 [48.7%] 和 623 名男性 [51.3%]）。原发性出血90例（3.0%），其中胃十二指肠动脉出血15例（16.7%），出血部位不明24例（26.7%），非胃十二指肠动脉出血51例（56.7%）。 23例患者发生继发性出血； 4 例（17.4%）的来源为胃十二指肠动脉。在所有出血事件 (n = 117) 中，19 例出血事件源自胃十二指肠动脉（所有胰十二指肠切除术中发生率为 16.2%，发生率为 0.63%）。胃十二指肠动脉出血更常与软腺体质地相关（14 [93.3%] vs 41 [62.1%]； P = .02）和后来的表现（中位数 [IQR]，21 [15-26] vs 10 天 [5-18]；P = .002）。 23 名患者接受了经验性胃十二指肠动脉栓塞或支架置入术，其中 7 名（30.4%）随后出现继发性出血。 20% 的胃十二指肠动脉栓塞/支架治疗（8/40 例患者），包括 13%（3/13 例患者）的经验性治疗，与显着的发病率（7 例肝梗塞、4 例胆管狭窄）和 90 天死亡率相关患有这些并发症的患者的发生率为 38.5% (n = 5)，而没有这些并发症的患者的发生率为 7.8% (n = 6；P = .008)。出血患者的 90 天死亡率为 12.2% (n = 11)（原发性胃十二指肠出血患者为 3 名 [20%]，其他所有患者为 8 名 [10.7%]；P = 0.38），而出血患者的 90 天死亡率为 2% (n = 59)结论和相关性在这项研究中，胰腺切除术后出血并不常见，而且出血范围很广，胃十二指肠动脉出血事件占少数。无明显近期出血后遗症的经验性胃十二指肠动脉栓塞/支架治疗与显着的发病率和再出血相关，不应作为常规做法。成功治疗胰腺切除术后出血需要仔细评估所有潜在来源，即使在胃十二指肠动脉缓解后也是如此。