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• W2090329381 abstract "The report by Reber et al.1Reber PU Baer HU Patel AG Triller J Buchler MW Life-threatening upper gastrointestinal tract bleeding caused by ruptured extrahepatic pseudoaneurysm after pancreatoduodenectomy.Surgery. 1998; 124: 114-115Abstract Full Text Full Text PDF PubMed Scopus (68) Google Scholar from Bern, Switzerland, while documenting an unusual complication after pancreatoduodenectomy and extended lymphadenectomy, highlights three important issues, one theoretical and two practical. First, do extended resections, especially those involving formal lymphadenectomies (and thus skeletonizing major vascular structures), increase operative morbidity? Some reports suggest that operative morbidity and mortality are little affected by the extended scope of these operations.2Fortner JG “Radical” abdominal cancer surgery: current state and future course.Jpn J Surg. 1989; 19: 503-509Crossref PubMed Scopus (20) Google Scholar, 3Fuhrman GM Leach SD Staley CA Cusack JC Charnsangavej C Cleary KR et al.Rationale for en bloc vein resection in the treatment of pancreatic adenocarcinoma adherent to the superior mesenteric-portal vein confluence.Ann Surg. 1996; 223: 154-162Crossref PubMed Scopus (360) Google Scholar, 4Iacono C Bortolasi L Facci E Falezza G Prati G Mangiante G et al.Does extended pancreaticoduodenectomy increase operative morbidity and mortality vs standard pancreaticoduodenectomy?.J Gastrointestinal Surg. 1997; 1: 446-453Crossref PubMed Scopus (21) Google Scholar In contrast, two recent prospective multicenter trials of resection for gastric cancer found that operative morbidity and mortality were quite recognizably increased after extended resections.5Bonenkamp JJ Songun I Hermans J Sasako M Welvaart K Plukker JTM et al.Randomized comparison of morbidity after D1 and D2 dissection for gastric cancer in 996 Dutch patients.Lancet. 1995; 345: 745-748Abstract PubMed Scopus (662) Google Scholar, 6Cuschieri A Fayers P Fielding J Craven J Bancewicz J Joypaul V Cook P the Surgical Cooperative Group Postoperative morbidity and mortality after D1 and D2 resections for gastric cancer: preliminary results of the MRC randomized controlled surgical trial.Lancet. 1996; 347: 995-999Abstract PubMed Scopus (627) Google Scholar The report from Bern suggests added risks after extended pancreatic resections as well. Although pseudoaneurysms of the gastroduodenal artery rarely occur after a standard pancreatoduodenectomy, the possibility of greater risk caused by operative trauma to arteries in the path of dissection should be weighed and evaluated in further studies. Second, how are these pseudoaneurysms best managed? The Bern group was able to control them by “superselective” angiographic embolization of the hepatic artery pseudoaneurysm, with minimal evidence of liver damage. However, truly selective embolization may be difficult or impossible, particularly when the site of the arterial defect is the stump of either the right gastric or gastroduodenal artery. The embolization risks occlusion of the common hepatic artery, with the attendant risk (perhaps 5%) of hepatic necrosis. One alternative that might (briefly) be entertained is direct surgical intervention to obtain proximal and distal control of the hepatic artery and to suture the bleeding point. Our experience has been that operating under such circumstances has been extraordinarily difficult and hazardous. Our preference (and advice) is to embolize first and accept the small risk of hepatic injury. Third, are there additional factors beyond arterial skeletonization in the pathogenesis of the pseudoaneurysm? Although Reber et al.1Reber PU Baer HU Patel AG Triller J Buchler MW Life-threatening upper gastrointestinal tract bleeding caused by ruptured extrahepatic pseudoaneurysm after pancreatoduodenectomy.Surgery. 1998; 124: 114-115Abstract Full Text Full Text PDF PubMed Scopus (68) Google Scholar did not detect a leak at the pancreaticojejunostomy, that possibility should be a foremost concern to the surgeon. Hemorrhage associated with pancreaticojejunal anastomotic breakdown is a life-threatening event7Brodsky JT Turnbull ADM Arterial hemorrhage after pancreatoduodenectomy: the “sentinel bleed”.Arch Surg. 1991; 126: 1037-1040Crossref PubMed Scopus (156) Google Scholar that, especially if not well controlled by drainage of the area, may require completion pancreatectomy.8Smith CD Sarr MG van Heerden JA Completion pancreatectomy following pancreaticoduodenectomy: clinical experience.World J Surg. 1992; 16: 521-524Crossref PubMed Scopus (75) Google Scholar" @default.
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• W2090329381 title "Causes and management of pseudoaneurysms" @default.
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