# A Multimodal Approach Utilizing Balloon Occlusion for Postpancreatectomy Hemorrhage: A Case Report

## TL;DR

A 79-year-old man with post-surgery bleeding was successfully treated using a combination of balloon occlusion and surgery to control the hemorrhage and preserve liver function.

## Contribution

This case report introduces the use of temporary common hepatic artery balloon occlusion as a bridge to surgical intervention for postpancreatectomy hemorrhage.

## Key findings

- Temporary balloon occlusion of the common hepatic artery stabilized hemodynamics and allowed for precise hemorrhage management.
- The patient's hepatic blood flow was preserved, and follow-up imaging confirmed long-term success.
- A multidisciplinary approach combining angiography and surgery improved outcomes in a complex postoperative hemorrhage case.

## Abstract

Postpancreatectomy hemorrhage (PPH) is a life-threatening complication following pancreaticoduodenectomy, requiring prompt and accurate diagnostic and therapeutic measures to ensure patient survival.

A 79-year-old man underwent robot-assisted pancreaticoduodenectomy for suspected intraductal papillary mucinous carcinoma. Postoperatively, he developed a pancreatic fistula and major bile leak, leading to a hemorrhagic event on postoperative day 6. Initial stabilization was achieved with intravenous fluids and blood transfusions, followed by emergent angiography, which identified bleeding from the gastroduodenal artery (GDA) stump. Due to the short length of the remaining GDA, simple embolization of the GDA stump was considered inadequate. Given the anatomy of the short proper hepatic artery (PHA) and its immediate bifurcation into the left and right hepatic arteries, coil embolization was feared to cause infarction of the entire liver, and even with stenting, the left hepatic artery (LHA) would have to be sacrificed. Temporary balloon occlusion of the common hepatic artery (CHA) was used to stabilize the hemodynamics, serving as a bridge to surgical intervention to maintain hepatic blood flow. Although it was an emergency laparotomy, intraoperative CHA balloon occlusion created a controlled environment, allowing for precise localization and effective management of the hemorrhage. The root of the GDA was ligated, and hepatic blood flow was preserved. The choledochojejunostomy leak was repaired by re-anastomosis. The patient was discharged following successful conservative management of the pancreatic fistula. Eight months post-intervention, follow-up imaging confirmed preserved hepatic arterial flow.

This case underscores the efficacy of a multidisciplinary approach in managing delayed PPH in hemodynamically stable patients. Comprehensive angiographic assessment, combined with temporary CHA balloon occlusion for bleeding control and meticulous surgical hemostasis, offers a viable strategy ensuring immediate and mid-term patient well-being.