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Hemorrhage After Pancreaticoduodenectomy: Does Timing Matter?
Gyulnara G. Kasumova*1, Mariam F. Eskander1, Tara S. Kent1, Sing Chau Ng1, A. J. Moser1, Muneeb Ahmed2, Douglas K. Pleskow3, Mark Callery1, Jennifer F. Tseng1
1Surgical Outcomes Analysis & Research, Beth Israel Deaconess Medical Center, Boston, MA; 2Radiology, Beth Israel Deaconess Medical Center, Boston, MA; 3Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA
Background: Hemorrhage after pancreaticoduodenectomy is a potentially fatal complication. Here we retrospectively review state-wide data to evaluate the latest incidence, type of hemorrhage, treatment modalities, and outcomes.
Methods: The Healthcare Cost and Utilization Project Florida State Inpatient Database was queried 2007-2011 for patients who underwent pancreaticoduodenectomy (Whipple) procedure for any indication. Data were analyzed to identify post-operative hemorrhage and procedures performed at time of index visit by ICD-9 codes. Patient characteristics and outcomes were compared by χ2. Day of hemorrhage was identified by day of intervention. Index length of stay (LOS) and cost were compared by Wilcoxon rank sum. Multivariate logistic regression model was generated for risk of hemorrhage during index visit.
Results: Of 2,548 patients who underwent pancreaticoduodenectomy, 217 (8.5%) developed post-operative hemorrhage during their index visit, with 139 (64.0%) requiring additional intervention. Interventions were classified as endoscopic (n=87), angiographic (n=48), or operative (n=47), with 35.3% (49/139) requiring multiple procedures. The rates of undergoing multiple procedures were the same regardless of whether the first intervention was endoscopic or angiographic, with 39% in both groups requiring at least one additional procedure. The overall mortality during index visit was 5.7%. Mortality was significantly higher in those patients who had post-operative hemorrhage (24.9%) vs not (4.0%) (p<0.0001). The median post-operative day of hemorrhage for those undergoing a procedure was 7 (IQR: 1-15). Mortality was significantly higher when post-operative hemorrhage occurred during the second week (post-operative days 8-14) vs the first week (post-operative days 0-7) at 53.6% vs 21.6%, respectively (p=0.007). The index LOS and total cost of inpatient care were significantly higher for those with hemorrhage, median LOS 22 days (IQR: 14-40) vs 13 days (IQR: 9-19) (p<0.0001), median cost ,296 (IQR: ,888-,733) vs ,300 (IQR: ,712-,708) (p<0.0001). On multivariate analysis, male sex (OR 1.56, p=0.003), vascular resection (OR 1.88, p=0.017), very low hospital volume (<7 Whipples per year; OR 1.62, p=0.016), and post-operative intra-abdominal/wound infection (OR 2.31 p<0.0001) were independent predictors for risk of hemorrhage following Whipple procedure during index visit.
Conclusions: Hemorrhage following pancreaticoduodenectomy remains a common complication, resulting in significantly increased mortality, LOS, and cost burden. Our data demonstrate that late hemorrhage, during the second post-operative week, carries approximately 2x the mortality of early post-operative hemorrhage. This suggests that early vs late hemorrhage may have different etiologies and may require differing treatment approaches.
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