Delayed Massive Hemorrhage after Pancreatoduodenectomy Successfully Treated by Arterioportal Shunting and Longmire Method

Abstract

We report a case of delayed massive hemorrhage from the common hepatic artery (CHA) that was successfully treated after pancreatoduodenectomy (PD) with arterioportal shunting to compensate for the sacrificed arterial flow to the liver secondary to the ligation of CHA. The choledocho-jejunostomy was performed to expose the operative field, which was reconstructed electively with intrahepatic biliary-jejunostomy. A 76-year-old man with a diagnosis of middle bile duct cancer underwent subtotal stomach preserving pancreatoduodenectomy. The procedure was complicated with pancreatic fistula and intra-abdominal infections. Subsequently the patient underwent surgery for an emergent exploratory laparotomy for massive intra-abdominal bleeding 17 days after surgery. The bleeding was from behind the choledocho-jejunostomy, which was removed to identify the bleeding point. The bleeding was from CHA, which did not look feasible to reconstruct because of the fragility of the arterial wall. Therefore, CHA was ligated and ileocolic arteriovenous shunting was performed in order to improve oxygenation of the liver via the portal vein. We chose not to undergo reconstruction of the choledocho-jejunostomy during the emergent operation. Eight months after the primary surgery, intrahepatic biliary-jejunostomy was successfully performed with Longmire’s method attempting to avoid adhesiolysis. He is alive at 24 months after the primary operation without recurrence.