title: Nonsurgical management of ruptured pseudoaneurysm in patients with hepatobiliary pancreatic diseases.
abstract: OBJECTIVE
  Rupture of a pseudoaneurysm is an unusual complication after surgical and interventional treatments in patients with hepatobiliary pancreatic diseases. However, it occurs abruptly and often results in a lethal outcome. The aim of this study was to retrospectively analyze our experiences of cases of rupture of pseudoaneurysms for providing appropriate therapeutic planning.
  
  
  METHODS
  Between 1985 and 1998, we observed ruptures of pseudoaneurysms in 14 of 910 patients with hepatobiliary pancreatic diseases--six after pancreaticoduodenectomy, three after hepatic resection, two after hepatopancreaticoduodenectomy, two after percutaneous transhepatic biliary drainage, and one after gastrojejunostomy. Thirteen of the 14 patients underwent emergency angiography and transcatheter arterial embolization (TAE) or infusion therapies, and one of the 13 patients underwent surgical hemostasis because of incomplete hemostasis with TAE. The other patient, who did not undergo emergency angiography, had surgical hemostasis initially.
  
  
  RESULTS
  TAE achieved hemostasis in 11 of 13 patients (85%), but only incomplete hemostasis in the remaining two patients. Of these two patients, one underwent laparotomy, but died of multiple organ failure (MOF) at 6 days after surgical hemostasis. The other died at 1 day after emergency angiography. Ten of 11 patients who obtained complete hemostasis by means of TAE could later be discharged, but one patient died of liver failure, and/or MOF. One patient who underwent laparotomy initially without angiography died of MOF at 43 days after the operation. The onset of rupture of a pseudoaneurysm was a mean of 35.4 days (range 12-76) after surgical or interventional procedures. The warning prodromal symptoms were upper abdominal oppression, nausea, and backache before the rupture of pseudoaneurysms. Fever, leukocytosis. hyperbilirubinemia, anastomotic leak, and intraabdominal abscess were frequent persistent signs in these patients.
  
  
  CONCLUSIONS
  If the warning prodromal symptoms appear in patients along with these persistent signs, the impending rupture of pseudoaneurysms should be suspected. Thereafter, a diagnostic angiography should be performed immediately to enable early diagnosis and embolization therapy for rupture of pseudoaneurysms when hemorrhagic episodes appear in these patients. Early detection and immediate embolization might bring about a favorable outcome in patients with hepatobiliary pancreatic diseases who encounter rupture of pseudoaneurysms after surgical and interventional treatments.
authors.affiliation: First Department of Surgery, School of Medicine, Chiba University, Japan.
authors.forename: A
authors.initials: A
authors.lastname: Okuno
authors.forename: M
authors.initials: M
authors.lastname: Miyazaki
authors.forename: H
authors.initials: H
authors.lastname: Ito
authors.forename: S
authors.initials: S
authors.lastname: Ambiru
authors.forename: H
authors.initials: H
authors.lastname: Yoshidome
authors.forename: H
authors.initials: H
authors.lastname: Shimizu
authors.forename: K
authors.initials: K
authors.lastname: Nakagawa
authors.forename: Y
authors.initials: Y
authors.lastname: Shimizu
authors.forename: Y
authors.initials: Y
authors.lastname: Nukui
authors.forename: N
authors.initials: N
authors.lastname: Nakajima
mesh_terms: D000328:Adult; D000368:Aged; D017541:Aneurysm, False / Q000628:therapy*; D017542:Aneurysm, Ruptured / Q000628:therapy*; D001650:Bile Duct Neoplasms / Q000601:surgery*; D005260:Female; D005706:Gallbladder Neoplasms / Q000601:surgery*; D006801:Humans; D008107:Liver Diseases / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D010190:Pancreatic Neoplasms / Q000601:surgery*; D011183:Postoperative Complications / Q000628:therapy*; D012189:Retrospective Studies