Causes And Countermeasures Of Hemorrhage After Laparoscopic Pancreaticoduodenectomy

Objective To explore the risk factors of post pancreaticoduodenectomy hemorrhage(PPH)after laparoscopic pancreaticoduodenectomy and strategies for PPH occurs,so as to improve the safety of laparoscopic pancreaticoduodenectomy(LPD).Methods The clinical data of 278 patients undergoing LPD at hepatobiliary and pancreatic surgery department of Zhejiang Provincial People’s Hospital and Zhejiang Provincial from January 2013 to January 2021 were retrospectively analyzed,and they were divided into bleeding group(n=26)and non-bleeding group(n=252)according to postoperative bleeding.Clinical factors including the patient’s gender,age,combined diabetes or not,combined hypertension or not,preoperative hemoglobin,total bilirubin level,preoperative biliary drainage or not,operation time,intraoperative bleeding volume,blood transfusion or not,tumor size,postoperative pancreatic fistula,postoperative biliary fistula,abdominal infection,and operator experience were selected for single factor analysis.Single factors with statistical significance were screened using Logistic regression analysis to conduct multi-factor analysis to explore the risk factors of PPH.To analyze the clinical data of PPH patients,and summarize corresponding diagnosis and treatment strategies.Results 1.Among 278 patients undergoing LPD,26 patients had PPH,an incidence of 9.35%(26/278),24 patients had abdominal hemorrhage(2 patients had hemorrhage of common hepatic artery,2 patients had hemorrhage of gastroduodenal artery stump,2 patients had hemorrhage of left gastric artery,1 patient had hemorrhage of venae mesenterica inferior,2 patients had hemorrhage of larteria hepatica propria,2 patients had portal vein hemorrhage,1 patient had hemorrhage of pancreas stump,1 patient had gastric lesser curvature side hemorrhage);10 patients had gastrointestinal hemorrhage(4 patients had pancreaticoduodenostomy,2 patients had gastrointestinal anastomosis,2 patients had bilioenteric anastomosis,and 2 patients had stress gastric ulcer);2 patients’ hemorrhage location was unknown.2.Single factor analysis showed that preoperative total bilirubin≥ 171μmol/L,operation time≥ 6h,intraoperative bleeding volume≥ 500ml,tumor size≥ 3cm,p postoperative pancreatic fistula and postoperative abdominal infection were significantly correlated with the occurrence of PPH(P<0.05).Multi-factor analysis showed that intraoperative bleeding volume≥500ml(OR=2.614,95%CI:1.042～6.557),postoperative pancreatic fistula(OR=5.857,95%CI:2.272～15.100)and postoperative abdominal infection(OR=2.975,95%CI:1.069～8.279)were independent risk factors of PPH.3.2 patients of A-grade PPH were improved after conservative treatment;1 patient among 24 B-grade PPH were improved after conservative treatment,3 patients received gastroscopic hemostasis,2 patients received interventional embolization hemostasis,6 patients were placed with film scaffold for hemostasis,13 patients received surgery treatment:2 patients underwent portal vein repair;1 patient underwent venae mesenteric inferior repair;1 patient underwent gastric duodenal arterial residual stump repair;1 patient underwent pancreatic stump repair;3 patients received in situ repair of pancreaticoduodenostomy;1 patient underwent Roux-en-Y Pancreaticointestinal reanastomosis;1 patient received gastrointestinal anastomosis suture hemostasis+percutaneous endoscopic jejunostomy;1 patient received retinal sewing hemostasis;2 patients received bilioenteric anastomosis repair+biliary "T" tube drainage.Among the 26 patients with PPH,18 were cured and discharged,8 patients died,a mortality rate of 30.8%(8/26).Conclusion 1.Preoperative total bilirubin≥171 μmol/L,operation time>6 h,and tumor size≥3 cm were risk factors for postoperative PPH in LPD patients,but were not independent risk factors.2.Postoperative pancreatic fistula,intraoperative bleeding volume ≥ 500 ml,postoperative abdominal infection are independent risk factors of PPH for patients with LPD.Postoperative pancreatic fistula is the most dangerous factor.3.When PPH occurs,it is necessary to actively perform enhanced CT,gastroscopy and DSA on the basis of conservative treatment to detect the hemorrhage location and carry out corresponding hemostasis,and surgical treatment should be performed if4.necessary.5.The liver function should be reasonably improved before surgery,and the operation process should be optimized during surgery.Reduce postoperative wound bleeding,anastomotic leakage,and have a critical preventive effect on PPH.6.Strengthening management during perioperative period and keeping vigilant for the harm of sentinel bleed.