Liver Necrosis and Hemorrhage due to Gastroduodenal Artery Pseudoaneurysm after total Pancreatectomy. Report of a case

Although mortality after pancreatectomy in high-volume centers is less than 3%, morbidity is still as high as 18-52%. Postpancreatectomy vasculary complication is less frequent but much mortal than anastomotic problems. Postpancreatectomy vasculary complication is a life-threatening entity and it must be managed urgently. Here we report a case treated with emergent laparotomy for delayed liver ischemia and massive bleeding after total pancreatectomy. Patient was discharged without any complication at the 3rd week of emergent laparotomy for aneurismatic hemorrhage. Upper gastrointestinal bleeding in the late postoperative period following pancreatoduodenectomy should alert the surgeon to the possibility of a ruptured visceral vasculary pseudoaneurysm. Case Report Liver Necrosis and Hemorrhage due to Gastroduodenal Artery Pseudoaneurysm after total Pancreatectomy. Report of a case Kurşat Rahmi Serin, Muharrem Oner and Nadir Adnan Hacım* Surp Pırgic Ermanian Hospital, Zeytinburnu, Istanbul, Turkey Received: 15 October, 2018 Accepted: 24 October, 2018 Published: 25 October, 2018 *Corresponding author: Nadir Adnan Hacım, Surp Pırgic Ermanian Hospital, Zeytinburnu, Istanbul, Turkey, E-mail: adnanhcm@hotmail.com


Introduction
The most commen causes of developing pseudoaneursym after visceral surgery are infection and the enzymatic contamination, especially after GI surgery [1]. A ruptured pseudoaneurism with bleeding into the gastrointestinal tract, pancreatic duct, retroperitoneum, or peritoneal cavity is still lifethreatening condition and mortality rate is still more than 15% in the era of modern surgery and minimally invasive radiological procedures [2][3][4]. The development of pseudoaneursyms after upper abdominal surgery is rare and it especially occurs after biliary and pancreatic arcade constitue [5].

Case Report
Total pancreatectomy and splenectomy was performed for pancreatic adenocarcinoma in a 70 years-old man. He was discharged at the 7 th day of the surgery without any complication but 2 days after discharged he readmitted to hospital with uneasiness, weakness and subfebrile fewer (37.5'C). He had anemia in his laboratoury and leukocytosis.
Upper GI endoscopy planned and bleeding from gastrojejunal anastomosis was seen. Bleeding stopped with endoscopic sclerotherapy. During his stay he had fever above 38'C,

Discussion
Bleeding complication after pancreatectomy can be seen rarely due to ruptured visceral vasculary pseudoaneurysms [2,4,5]. This rare but mortal complication usually necessitates emergent surgery [5]. Stabile et al. reported its mortality rate more than 43% [6]. Delayed diagnosis and diffi culties are the major obstacles in this high mortality rate. Bleeding complication after pancreatectomy or major abdominal surgery is especially seen at the upper gastrointestinal tract or either at the anastomotic site, especially after anastomotic problems, this primarily suggest endoscopic procedure for diagnosis and moreover for the treatment. Therefore, it must be kept in mind that it is diffi cult to enter the afferent jejunal loop by endoscope to detect the bleeding site and mucosal erosions or intermittent bleeding can be misleading and even hazardous causing delay in defi nitive treatment [7][8][9][10]. In our case, in the early postoperative days he had mild bleeding from the anastomotic site which controlled by endoscopic sclerotherapy and he had surgical side infection. Later on, he had massive bleeding from the visceral vasculature that was necessitated surgery, might be caused by this endoscopic intervention and infection.
Gastroduodenal artery is the most commen site for pseudoanevrism developing after pancreatectomies especially after Whipple's procedure. This is usually associated as a result of leakage from the pancreaticojejunal anastomosis which causes infection or damages arteries [7,8]. Pancreatic proteolitic enzymes and destruction of the vessel walls during the lymphatic dissection are discussed for the local arteritis [3,[11][12][13][14][15].
Intraabdominal infection is found in the great majority of these patients. As a matter of fact, in our cases, early postoperative complaints and surgical fi ndings were made us consider about infection but there is no chance for the leakage.
We didn't use ultrasonography to detect bleeding especially in hemodinamically instable patients. Contrast-enhanced computerized tomography and CT angiography can distinguish intraabdominal bleeding and also pseudoaneurysms [9].
Over the past decades, visceral angiography has improved the diagnostic and also therapeutic accuracy for visceral pseudoaneurysms [5]. Embolization with coils or covered stent implantation (especially in hemodynamic stable patients) became the fi rst choice treatment modality [5,12,13]. However, angiography may not be helpful in mild or intermittent bleeding for showing and treating the site [12]. Moreover, revascularization and recurrent bleeding are not rare after intravasculary treatments. Salam et al. reported 37% recurrent bleeding in their series [14]. We couldn't perform angiography for neither diagnosis nor treatment because of the hemodynamically instability of the patient (he was in shock due massive bleeding and in the cause of infection) and due to the hospital set-up, also.
Surgical exploration at the early postoperative period is also diffi cult, due to dense adhesions and fi brosis caused by previous surgery and infection. Furthermore an intact anastomosis can be damaged during dissection of the aneurysmatic artery. Since ligation of the artery alone may be insuffi cient, a completion pancreatectomy seems more reasonable, especially in anastomotic leakage [6].
In conclusion, pseudoaneurysms must be kept in mind as a cause of massive hemorrhage in the late postoperative period after pancreatectomies, particularly in patients who had postoperative anastomotic leakage and infective complications.