title: Diagnosis and Treatment of Abdominal Arterial Bleeding After Radical Gastrectomy: a Retrospective Analysis of 1875 Consecutive Resections for Gastric Cancer.
abstract: BACKGROUND
  Massive abdominal arterial bleeding is an uncommon yet life-threatening complication of radical gastrectomy. The exact incidence and standardized management of this lethal morbidity are not known.
  
  
  METHODS
  Between January 2003 and December 2013, data from 1875 patients undergoing radical gastrectomy with D2 or D2 plus lymphadenectomy were recorded in a prospectively designed database from a single institute. The clinical data and management of both early (within 24 h) and late (beyond 24 h) postoperative abdominal arterial hemorrhages were explored. For late bleeding patients, transcatheter arterial embolization (TAE) and re-laparotomy were compared to determine the better initial treatment option.
  
  
  RESULTS
  The overall prevalence of postoperative abdominal arterial bleeding was 1.92 % (n = 36), and related mortality was 33.3 % (n = 12). Early and late postoperative bleedings were found in 6 and 30 patients, respectively. The onset of massive arterial bleeding occurred on average postoperative day 19. The common hepatic artery and its branches were the most common bleeding source (13/36; 36.1 %). All the early bleeding patients were treated with immediate re-laparotomy. For late bleeding, patients from the TAE group had a significantly lower mortality rate than that of the patients from the surgery group (7.69 vs. 56.25 %, respectively, P = 0.008) as well as a shorter procedure time for bleeding control (2.3 ± 1.1 vs. 4.8 ± 1.7 h, respectively, P < 0.001). Four rescue reoperations were performed for TAE failures; the salvage rate was 50 % (2/4). Ten patients developed massive re-bleeding after initial successful hemostasis by either TAE (5/13) or open surgery (5/16). Three out of the 10 re-bleeding patients died of disseminated intravascular coagulation (DIC), while the other 7 recovered eventually by repeated TAE and/or surgery.
  
  
  CONCLUSIONS
  Abdominal arterial bleeding following radical gastrectomy tends to occur during the later phase after surgery, with further complications such as abdominal infection and fistula(s). For late bleeding, TAE can be considered as the first-line treatment when possible.
authors.affiliation: Department of Gastrointestinal Surgery, The First Affiliated Hospital of Sun Yat-sen University, 510080, No. 58, 2nd Zhongshan Road, Guangzhou, Guangdong Province, China.
authors.forename: Jie
authors.initials: J
authors.lastname: Yang
authors.affiliation: Department of Gastrointestinal Surgery, The First Affiliated Hospital of Sun Yat-sen University, 510080, No. 58, 2nd Zhongshan Road, Guangzhou, Guangdong Province, China.
authors.forename: Xin-Hua
authors.initials: XH
authors.lastname: Zhang
authors.affiliation: Department of Interventional Radiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China.
authors.forename: Yong-Hui
authors.initials: YH
authors.lastname: Huang
authors.affiliation: Department of Interventional Radiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China.
authors.forename: Bin
authors.initials: B
authors.lastname: Chen
authors.affiliation: Department of Gastrointestinal Surgery, The First Affiliated Hospital of Sun Yat-sen University, 510080, No. 58, 2nd Zhongshan Road, Guangzhou, Guangdong Province, China.
authors.forename: Jian-Bo
authors.initials: JB
authors.lastname: Xu
authors.affiliation: Department of Gastrointestinal Surgery, The First Affiliated Hospital of Sun Yat-sen University, 510080, No. 58, 2nd Zhongshan Road, Guangzhou, Guangdong Province, China.
authors.forename: Chuang-Qi
authors.initials: CQ
authors.lastname: Chen
authors.affiliation: Department of Gastrointestinal Surgery, The First Affiliated Hospital of Sun Yat-sen University, 510080, No. 58, 2nd Zhongshan Road, Guangzhou, Guangdong Province, China.
authors.forename: Shi-Rong
authors.initials: SR
authors.lastname: Cai
authors.affiliation: Department of Gastrointestinal Surgery, The First Affiliated Hospital of Sun Yat-sen University, 510080, No. 58, 2nd Zhongshan Road, Guangzhou, Guangdong Province, China.
authors.forename: Wen-Hua
authors.initials: WH
authors.lastname: Zhan
authors.affiliation: Department of Gastrointestinal Surgery, The First Affiliated Hospital of Sun Yat-sen University, 510080, No. 58, 2nd Zhongshan Road, Guangzhou, Guangdong Province, China. y_he_sysu@126.com.
authors.forename: Yu-Long
authors.initials: YL
authors.lastname: He
authors.affiliation: Department of Gastrointestinal Surgery, The First Affiliated Hospital of Sun Yat-sen University, 510080, No. 58, 2nd Zhongshan Road, Guangzhou, Guangdong Province, China. dr_lancetty@163.com.
authors.forename: Jin-Ping
authors.initials: JP
authors.lastname: Ma
mesh_terms: D000005:Abdomen / Q000098:blood supply*; D000368:Aged; D004621:Embolization, Therapeutic; D005260:Female; D005743:Gastrectomy / Q000009:adverse effects*; D006499:Hepatic Artery; D006801:Humans; D007813:Laparotomy; D008297:Male; D008875:Middle Aged; D019106:Postoperative Hemorrhage / Q000175:diagnosis / Q000209:etiology* / Q000628:therapy; D012086:Reoperation; D012189:Retrospective Studies; D013274:Stomach Neoplasms / Q000601:surgery*; D016896:Treatment Outcome
keywords: Angiography; Gastric cancer; Hemostasis; Lymphadenectomy; Postoperative arterial bleeding; Radical gastrectomy; Re-laparotomy