Case Report

Major abdominal haemorrhage following total pancreatectomy. How late can it be?

¹William Howden MD, MS, ¹SamAlhayo MD, MPH, ¹Ramesh Damodaran Prabha MBBS, FRACS, ²Ross Copping MBBS, FRANZCR, ^2,3Yehia El Hgar MBBS, FRANZCR ¹Amitabha Das FRACS

• ^{*1.Department of Gastrointestinal Surgery, Liverpool Hospital, NSW, Australia}
• ^{*2.Department of Interventional Radiology, Liverpool Hospital, NSW, Australia}
• ^{*3.Department of Medicine, University of NSW, Australia}

• Submitted: Wednesday, 24 February 2021
• Accepted: Friday, 19 March 2021
• Published: Monday 19 April 2021
  

This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited

Abstract

Introduction

This report presents the second case and most delayed case to-date of a ruptured pseudoaneurysm following-total pancreatectomy. Pseudoaneuryms post-partial pancreatoduodenectomy are a rare, but well documented event. A ruptured pseudoaneurysm following total pancreatectomy is extremely uncommon, and without a clear pathophysiological mechanism.

Case description

A 60 year old male presents to ED moribund following acute onset abdominal pain, 321 days post total pancreatectomy. A multi-phase CT scan demonstrated a large ruptured pseudoaneurysm in the periportal area. The patient is resuscitated, receiving 16 units of packed red blood cells and the aneurysm is embolised by interventional radiology and makes a full recovery after recovering in intensive care before being discharged two weeks later.

Conclusion

This case highlights the need for the treating doctor to consider post-pancreatectomy haemorrhage in any total pancreatectomy patient, even without remnant pancreatic parenchyma and almost a year post-operatively.

Keywords

Pseudoaneurysm, angioembolisation

Introduction

Post-pancreatectomy haemorrhage (PPH) is well documented as one of the leading causes of morbidity and mortality following pancreatic surgery. All but one of the cases available in the English literature are following partial pancreatectomy, and therefore have remnant pancreatic parenchyma [1, 2]. PPH following total pancreatectomy is extremely uncommon and without a clear pathophysiological mechanism. This report presents the second case and most delayed case to-date of a ruptured pseudoaneurysm following-total pancreatectomy.

The International Study Group of Pancreatic Surgery (ISGPS) defines PPH based on three parameters of its onset, site of bleeding, severity and clinical impact into grades of A, B and C [3]. It is more common in the immediate or early post-operative period following subtotal pancreatectomy procedures. Delayed PPH following total pancreatectomy (TP) is exceptionally uncommon.

Pseudoaneurysms are a common cause of delayed post-operative haemorrhage following pancreatectomy. This occurs secondary to intrabdominal abscesses or pancreatic fistulae causing enzymatic degradation and weakening of the vessel wall [4, 5]. A review of current English literature demonstrates only one example of a comparable case, presenting a presentation of PPH occurring 35 days post completion pancreatectomy [1, 2].

In the case of ruptured pseudoaneurysms, a high index of suspicion and prompt management is paramount to patient survival. Minimally invasive endovascular management, such as that of transcatheter arterial embolisation or placement of an arterial stent is often considered first-line intervention at most centres worldwide [5, 6], and certainly in Australia [4]. Endovascular control of bleeding is associated with a significantly lower rate of mortality than laparotomy (16% vs 37% respectively) [1]. A high index of suspicion is essential to minimise the significant morbidity and mortality associated with PPH

Case Report

A 60year old male was admitted to an Australian tertiary hospital moribund following acute onset abdominal pain. Notably, 321 days prior he had undergone total pancreatectomy, splenectomy and cholecystectomy for a pancreatic adenocarcinoma at another hospital. His post operative course was complicated by emergency returns to theatre for a post op haematoma and complete wound dehiscence. He recovered well enough to receive adjuvant chemotherapy, however this was ceased just short of completion due to therapeutic agent intolerance. His post operative surveillance scan at eight months showed no disease recurrence.

On presentation to our hospital, the patient was tachycardic with an undetectable blood pressure. Appropriate resuscitation including activation of massive transfusion protocol (MTP) was undertaken. Permissive hypotension was allowed whilst a multi-phase CT scan of his abdomen was performed to demonstrated large volume peritoneal fluid and 37x35mm density at the porta hepatis with progressive contrast enhancement on arterial and delayed phases (Figure 1). These findings were in keeping with a ruptured pseudoaneurysm without confident identification of the feeding vessel.

Figure 1 - Axial images of the triple-phase CT scan demonstrating progressive contrast enhancement of the lesion (arrow) across non-contrast (A), arterial (B) and delayed (C) phases

The patient proceeded to angiography, identifying the vessel as the common hepatic artery (CHA), just proximal to the gastroduodenal stump (Figure 2). The pseudoaneurysm and CHA were embolised with a cast of histoacryl glue and lipiodol emulsion. Repeat angiography demonstrated no residual filling of the pseudoaneurysm and complete embolisation of the CHA (Figure 3) No additional feeding vessels via the superior mesenteric artery were identified.

Figure 2 - Pre-embolisation angiogram demonstrating the neck of the pseudoaneurysm (arrow) proximal to the gastroduodenal stump clips

Figure 3 - Post-embolisation angiogram demonstrating successful embolisation of the pseudoaneurysm (arrow) extending into the inferior site of rupture with absence of flow into the proximal common hepatic artery (*)

He was transferred to the intensive care unit. A total of 16 units of packed red blood cells with fresh frozen plasma and pooled platelets were received by the end of the procedure at a 1:1:1 ratio, with intermittent haemodynamic instability within the procedure.

The patient’s liver function deteriorated briefly, returning to baseline over the following week supported by a N-acetylcysteine infusion. The patient was discharged two weeks after admission without significant morbidity.

Discussion

This case reports a patient with ISGPS C PPH. As discussed previously, it is of great importance to recognise a patient with PPH quickly in the emergency department or ward and to instigate appropriate resuscitation and definitive or temporising management in due course due to its high morbidity and mortality.

The pathophysiology of our encountered pseudoaneurysm is unclear; however, a possible cause could have been a periportal abscess causing weakness and fibrosis of the arterial wall. A microscopic intraabdominal abscess unable to be detected by CT may still have existed. Although less likely, the possibility of recurrence of the malignancy and subsequent vascular wall damage remains a consideration.

In the case presented, the decision made by the interventionalist to embolise both the aneurysm and the CHA was multifactorial, primarily due to the risk of rebleed or other nearby feeding vessels. No variant or accessory left hepatic artery was evident on angiography (Figure 2). which suggests tolerance of portal vein perfusion alone

Conclusions

This case presents an extraordinarily rare case of PPH following total pancreatectomy. It is only the second case of its kind reported in the literature [3] and presents the longest reported interval between index operation and haemorrhage at 321 days. Pseudoaneurysm and rupture should be an important differential in any post-pancreatectomy patient presenting with haemodynamic instability, even in the absence remnant parenchyma.

Learning points

• Post-pancreatectomy haemorrhage (PPH) is a rare event, but carries significant morbidity and mortality

• PPH is usually associated with remnant pancreatic parenchyma and pancreatic fistula formation

• For the post-pancreatectomy patient presenting with signs of shock, even in the absence of remnant pancreatic parenchyma (i.e., following total pancreatectomy), a high index of suspicion for PPH should remain

• Angioembolisation is an effective first-line management strategy in most cases of PPH.

Consent

Written informed consent was obtained from the patient for publication of case and accompanying images

Competing interests

Authors declare no competing interests

Authors contributions

WH carried out the literature search, draft of manuscript and editing of manuscript. SA carried out editing of the manuscript and clinical management of the patient. RC and YE carried out clinical management of the patient and input and editing of the manuscript. AD supervised and edited the manuscript. All authros read and approved the final version of the manuscript for publication.

Acknowledgements

None  

References

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