Prolonged operating time is a significant perioperative risk factor for arterial pseudoaneurysm formation and patient death following hemorrhage after pancreaticoduodenectomy

概要

Background:
　Arterial pseudoaneurysm is a rare but potentially fatal complication after pancreaticoduodenectomy (PD). Previous studies have evaluated risk factors that contribute to post pancreatectomy hemorrhage, its management and outcomes; however, no study has evaluated predictors of post-PD pseudoaneurysm formation. Therefore, this study aimed to evaluate the incidence and predictors associated with pseudoaneurysm formation and patient death caused by its rupture.

Patients and method:
　We retrospectively reviewed the data of 453 patients who underwent PD from April 2007 to February 2019 at Mie University Hospital. Pseudoaneurysm was defined as a hyperattenuating contrast-enhanced smooth-walled sac often round or oval with a possible neck adjacent to an artery, less apparent on delayed images on contrast-enhanced CT. Uni- and multivariate analysis were performed to identify risk factors associated with the development of pseudoaneurysm and death associated with pseudoaneurysm rupture. These identified risk factors were analyzed using the receiver operating characteristic (ROC) curve analysis to determine their optimal cut-off values.

Results:
　Among the 453 patients, the median age was 69 years and 61.4% of the patients were men. Pancreatic ductal adenocarcinoma was the most common preoperative diagnosis and indicator for PD (222/453, 49%). Twenty two patients (4.9%) developed pseudoaneurysm after PD. Median duration from surgery to detection of pseudoaneurysm was 17.0 (1-51) days. The locations of pseudoaneurysms were hepatic artery in 8, splenic artery in 3, gastroduodenal artery in 4, gastric artery in 2 and others in 5 patients, and 72.7% (16/22) of patients presented with hemorrhage. All pseudoaneurysms were treated using angioembolization. Lower age (<65.5 years, p 二 0.004), prolonged operation time (Cut off >610 min, p = 0.026) and postoperative pancreatic fistula (POPF) (p = 0.013) were the independent risk factors for development of pseudoaneurysm. 6 (27.3%) patients died due to rupture of pseudoaneurysm.

Conclusion:
　Prolonged operating time, younger age, and POPF grade B and C were identified as independent risk factors for pseudoaneurysm formation, whereas only prolonged operating time was identified as the risk factor of death related to pseudoaneurysm after PD. In these high-risk patients, early detection of pseudoaneurysm before its rupture might provide an optimal opportunity for prompt intervention that might result in reduced patient mortality.