Interventional radiology (IR) has been found to “significantly” reduce recovery time and prevent morbidity associated with re-exploration following major pancreatic surgery, which even in high-volume centres has a morbidity and mortality rate of between 30–50% in the literature. Published in the Journal of Clinical Interventional Radiology, the authors state that IR’s synergistic and less invasive role is “crucial” in managing postpancreatectomy complications.
“Interventional radiologists play a critical role in the management of patients with pancreatic and periampullary disease, seldom preoperatively and often postoperatively for the management of complications associated with pancreatic surgery,” states lead author Suyash Kulkarni on behalf of his team at Tata Memorial Centre in Maharashtra, India.
In recent years, Kulkarni et al continue, IR has been increasingly integrated into the treatment of postoperative pancreatic complications. Commonly performed procedures for the early successful management of complications are percutaneous image-guided drainage for intra-abdominal collections, postoperative pancreatic fistula placement, percutaneous transhepatic biliary drainage for patients with biliary leak or stricture, and angioembolization for patients with postpancreatectomy haemorrhage (PPH), the authors state. They emphasise that early identification of these complications and appropriate management is “vital” to successful outcomes in this patient population.
The focus of their study was to establish the role of IR in the management of potentially life-threatening postpancreatectomy complications such as PPH, thus preventing re-exploration. To do so, Kulkarni and colleagues enrolled 758 patients who underwent pancreatic surgery between January 2014 and December 2019. All patients who developed post-surgical complications within 90 days of primary hospitalisation were included. Complications were classified according to the International Study Group of Pancreatic Surgery (ISGPS).
The types of surgery included in the study were pancreatectomy (4%), pancreaticoduodenectomy (73.8%), enucleation (1%), pancreatectomy and vein resection (4.85%), and multivisceral pancreatic surgery (16.5%). Of the 758 patients included, 206 (27.2%) developed post-surgical complications. Of these, 46 patients (6%) experienced PPH, with 30 patients (3.96%) requiring intervention; 13 patients (43.3%) underwent angioembolization, of whom five (38.46%) died due to causes unrelated to PPH, while 17 patients (56.7%) underwent surgical re-exploration.
The authors note that the 90-day mortality rate in patients with PPH was 17.39%, which is comparable with other studies in the literature. For patients who underwent primary angioembolization for PPH, the mortality rate was 38.46%—which is not statistically significant, they detail. The causes of death for these five patients included biliary sepsis with multiorgan dysfunction, myocardial infarction, hepatic decompensation, and major hepaticojejunostomy and pancreatojejunostomy leaks. Kulkarni and colleagues state that “although PPH may have been a contributing factor, the causes of death were not directly related to the condition”.
“These five patients who underwent re-exploration were beyond the scope of management by IR,” state Kulkarni and colleagues, who explain that mortality rates in patients with PPH “remain high despite aggressive intervention”. They do note, however, that these patients also tend to have associated complications and comorbidities which contribute to increased mortality and morbidity rates. They describe that common comorbidities among this patient population are diabetes, hypertension, hypothyroidism and coronary artery disease; 45 patients in their study cohort presented with one comorbidity and 47 with multiple.
Elsewhere in their results, the researchers observed intra-abdominal fluid collections in 173 (22.8%) patients, with 147 (85%) undergoing image-guided interventions and 23 (13.3%) undergoing surgical re-exploration. The 90-day mortality rate after percutaneous image-guided intervention was 6.12% and after primary surgical re-exploration was 21.7%.
Among other results, the authors identified that biliary complications occurred in 31 patients (4%), of which 18 (58%) underwent image-guided intervention and 11 (35.5%) underwent surgical re-exploration. The 90-day mortality rates were 27.78% and 35.5% in the IR and surgical groups, respectively. Further, the incidence of pancreatic fistula was observed in 20% of patients, 91.8% of whom were prevented from undergoing surgical re-exploration by use of IR management. The 90-day mortality rate in patients who underwent percutaneous drainage was 2.7% and 30.3% in those who underwent primary surgical re-exploration.
“Image-guided interventions successfully prevented re-exploration in 61.5% of PPH cases, 88.9% of biliary complications, and 99.3% of intra-abdominal fluid collections,” state Kulkarni et al, emphasising the “pivotal role” IR plays in managing post-surgical complications.
“IR provides a minimally invasive alternative to surgical re-exploration, reducing recovery time and preventing morbidity associated with re-exploration,” say the authors. They highlight that “early recognition and prompt intervention” are key in patients with PPH, biliary leak and portal vein thrombosis, as these are conditions associated with high mortality and morbidity rates. However, in cases where surgical re-exploration is required, this is “often due to complications which are beyond the scope of percutaneous management”, Kulkarni et al point out.
“Despite the success of IR procedures, some patients may still require reoperation in situations such as anastomotic dehiscence, or peritonitis. Moreover, increased frequency of complications is associated with a higher risk of mortality,” the authors state.
Finalising thoughts on the present findings, Kulkarni and colleagues conclude that IR procedures are safe and effective, and represent a cooperative, minimally invasive approach to managing postpancreatectomy complications, to “reduce recovery time and prevent morbidity associated with re-exploration”.
