Treatment and Prevention of Intraabdominal Bleeding in Necrotizing Pancreatitis Patients Treated With a Step-Up Approach

Objectives A minimally invasive step-up (MIS) approach for management of necrotizing pancreatitis (NP) has been associated with reduced morbidity and mortality compared with open surgical techniques. We sought to evaluate bleeding complications in NP patients treated with a MIS approach and to describe the management and outcomes of these events. Methods An observational, cohort study was performed using a prospectively maintained NP database at a tertiary referral center from 2013 to 2019. Results Of 119 NP patients, 13% suffering bleeding events, and 18% underwent an intervention. There was a 6-fold higher mortality rate in patients with bleeding events (n = 3; 18.8%) compared with those without (n = 3; 2.9%) (P = 0.031). The most common intervention for hemorrhage control was endovascular coil embolization (75%), which was successful 88% of the time. Seven patients underwent prophylactic vascular intervention, which was 100% successful in preventing bleeding events from the embolized vessel. Conclusions Bleeding events in NP patients treated with a MIS approach are associated with a 6-fold increase in mortality. Endovascular intervention is an effective strategy for the management of bleeding events. Prophylactic embolization may be an effective technique for reducing bleeding complications.

[1]  K. Lillemoe,et al.  Improved Mortality in Necrotizing Pancreatitis with a Multidisciplinary Minimally Invasive Step Up Approach: Comparison to a Modern Open Necrosectomy Cohort. , 2020, Journal of the American College of Surgeons.

[2]  S. Rana,et al.  Complications of endoscopic ultrasound-guided transmural drainage of pancreatic fluid collections and their management , 2019, Annals of gastroenterology.

[3]  S. Varadarajulu,et al.  An Endoscopic Transluminal Approach, Compared With Minimally Invasive Surgery, Reduces Complications and Costs for Patients With Necrotizing Pancreatitis. , 2019, Gastroenterology.

[4]  Mihir S. Wagh,et al.  Increased Incidence of Pseudoaneurysm Bleeding With Lumen‐Apposing Metal Stents Compared to Double‐Pigtail Plastic Stents in Patients With Peripancreatic Fluid Collections , 2018, Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association.

[5]  M. Boermeester,et al.  Endoscopic or surgical step-up approach for infected necrotising pancreatitis: a multicentre randomised trial , 2018, The Lancet.

[6]  S. Bramhall,et al.  Pancreatitis: Preventing catastrophic haemorrhage , 2017, World journal of gastroenterology.

[7]  M. Boermeester,et al.  Minimally invasive and endoscopic versus open necrosectomy for necrotising pancreatitis: a pooled analysis of individual data for 1980 patients , 2017, Gut.

[8]  J. Mayerle,et al.  Delayed severe bleeding complications after treatment of pancreatic fluid collections with lumen-apposing metal stents , 2017, Gut.

[9]  John P. Neoptolemos,et al.  Outcomes From Minimal Access Retroperitoneal and Open Pancreatic Necrosectomy in 394 Patients With Necrotizing Pancreatitis , 2016, Annals of surgery.

[10]  Z. Tong,et al.  Risk Factors and Outcome for Massive Intra-Abdominal Bleeding Among Patients With Infected Necrotizing Pancreatitis , 2015, Medicine.

[11]  R. Schmid,et al.  Spontaneous Bleeding in Pancreatitis Treated by Transcatheter Arterial Coil Embolization: A Retrospective Study , 2013, PloS one.

[12]  S. Ilyas,et al.  Complications arising from splenic artery embolization: a review of an 11-year experience. , 2013, American journal of surgery.

[13]  M. Falconi,et al.  Minimally Invasive Necrosectomy Versus Conventional Surgery in the Treatment of Infected Pancreatic Necrosis: A Systematic Review and a Meta-Analysis of Comparative Studies , 2013, Surgical laparoscopy, endoscopy & percutaneous techniques.

[14]  P. Fockens,et al.  Treatment of necrotizing pancreatitis. , 2012, Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association.

[15]  S. Wicky,et al.  Angiographic intervention in patients with a suspected visceral artery pseudoaneurysm complicating pancreatitis and pancreatic surgery. , 2011, Archives of surgery.

[16]  R. Andersson,et al.  Major haemorrhagic complications of acute pancreatitis , 2010, The British journal of surgery.

[17]  M. Boermeester,et al.  A step-up approach or open necrosectomy for necrotizing pancreatitis. , 2010, The New England journal of medicine.

[18]  M. Biermer,et al.  Transluminal endoscopic necrosectomy after acute pancreatitis: a multicentre study with long-term follow-up (the GEPARD Study) , 2009, Gut.

[19]  K. Madan,et al.  Hemorrhage in Acute Pancreatitis: Should Gastrointestinal Bleeding Be Considered an Organ Failure? , 2008, Pancreas.

[20]  A. Andrén-sandberg,et al.  Potentially Fatal Bleeding in Acute Pancreatitis: Pathophysiology, Prevention, and Treatment , 2003, Pancreas.

[21]  B. Ammori,et al.  Haemorrhagic complications of pancreatitis: presentation, diagnosis and management. , 1998, Annals of the Royal College of Surgeons of England.

[22]  J. Göthlin,et al.  Preoperative angiographic diagnosis of bleeding aneurysms of abdominal visceral arteries. , 1969, Radiology.

[23]  S. Wilson,et al.  Reduced mortality from bleeding pseudocysts and pseudoaneurysms caused by pancreatitis. , 1983, Archives of surgery.

[24]  M. Anderson,et al.  Hemorrhagic complications of severe pancreatitis. , 1981, Surgery.