Elsevier

Surgery

Volume 137, Issue 3, March 2005, Pages 323-328
Surgery

Original communication
Management and outcome of hemorrhage due to arterial pseudoaneurysms in pancreatitis

https://doi.org/10.1016/j.surg.2004.10.009Get rights and content

Background

Arterial pseudoaneurysm formation in pancreatitis is a rare complication. The optimal treatment modality is controversial. Operative treatment and interventional treatment, either alone or as a temporizing method with a later operation, are options.

Methods

In this single-center, patient-based cohort study, we managed 35 patients (8 with necrotizing pancreatitis and 27 with chronic pancreatitis) with bleeding pseudoaneurysms treated over a period of 10.5 years with a median follow-up of 4.6 years. Angiography was performed depending on the patient's hemodynamic condition.

Results

Angiography had a sensitivity of 96% for 26 patients. Angiographic embolization as primary treatment was performed in 16 patients (61% embolization rate); there were 2 rebleeding complications. No patients required intervention for embolization complications after discharge. Nineteen patients (54%) underwent an operation, 9 urgently without angiographic evaluation. The overall mortality rate for the 35 patients was 20% (19% for embolization, 21% after an operation). For necrotizing pancreatitis, an advantage of angiographic embolization was observed (mortality in 2/5 vs 2/3 after surgery). Ligation or repair of the bleeding vessel was complicated by higher rebleeding rates (6/13) than partial pancreatectomy (1/6).

Conclusions

Concerns that angiographic embolization is unable to provide definitive hemostasis in both acute and chronic pancreatitis are unfounded. In the operative treatment of chronic pancreatitis, partial pancreatectomy is superior to vessel ligation, depending on the patient's general condition and degree of pancreatic inflammation. We propose an algorithm for the management of arterial pseudoaneurysms in the setting of pancreatitis.

Section snippets

Patients and methods

Over a period of 10.5 years, 35 patients (28 male, 7 female) with pancreatitis and arterial pseudoaneurysms were admitted to our surgical department. Data from these patients regarding bleeding complications caused by pseudoaneurysms were reviewed from our prospective pancreas database. The average age of all patients with pseudoaneurysms was 51 years (range, 28-75). Alcohol abuse was the main cause of pancreatitis (86%), and 5 patients had biliary pancreatitis. There was no significant

Presentation

The most common symptoms for all 35 patients with pseudoaneurysms were pain and gastrointestinal hemorrhage, which occurred in 16 patients (4 with hemosuccus pancreaticus, 3 with hemobilia). Seventeen patients (49%) presented with an acute onset of severe abdominal pain. Fifteen (43%) presented with massive hemorrhage as evidenced by rapidly worsening anemia and hemorrhagic shock.

The most common arteries involved were the splenic, intrapancreatic, and gastroduodenal arteries. The involved

Discussion

Gastrointestinal bleeding complications in patients with either acute or chronic pancreatitis usually are attributed to peptic ulcers, erosive gastritis, or esophageal and gastric fundus varices. Nevertheless, pseudoaneurysmal bleeding is a serious, though rare, complication of pancreatitis. For this reason, it is unlikely that randomized trials will be forthcoming to provide evidence for the relative merits of operative or radiologic intervention. Therefore, the caregiver must rely on the data

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