Massive hemorrhage of the afferent loop after pylorus-preserving pancreaticoduodenectomy

Abstract

A 66-year-old woman underwent pylorus-preserving pancreaticoduodenectomy (PPPD) and Child reconstruction with Braun anastomosis for carcinoma of the ampulla of Vater in March 2007 ; final findings were non invasive tubular adenocarcinoma pTis pN0 H0 P0 M(-) Stage0 Resection A, according to general rules specified in Japanese Classification of cancer of the bile duct. She reported rectal bleeding on postoperative day (POD) 26 and POD 28. Scintigram for gastrointestinal hemorrhage showed accumulation of radioisotope in the small intestine and superior mesenteric artery (SMA) angiography showed that the contrast agent leaked from the jejunal artery. Emergency endoscopic examination was performed and bleeding from the afferent loop was arrested using an endoscopic clip. The patient recovered well and was discharged on POD 44. In the Child method with Braun anastomosis, the jejunal loop anastomosed to the duodenal bulb was directly exposed to the gastric juice without neutralization by pancreatic juice from the oral jejunal limb. The gastrointestinal reconstruction method without a mixture of gastric juice and pancreatic juice may be a causal factor for the marginal ulceration that occurs after PPPD.