CASE REPORT: LATE POSTOPERATIVE ARTERIAL HEMORRHAGE AFTER FULL ROBOTIC GASTRECTOMY WITH D2 LYMPHADENECTOMY

Case Report: G.A.A., a 44-year-old male patient, without comorbidities, diagnosed with gastric adenocarcinoma and preoperative staged as cT2N2M0. He underwent neoadjuvant treatment with Flot 4 protocol, without lesion regression. Full robotic gastrectomy with D2 lymphadenectomy and transmesocolic Roux-en-Y reconstruction were performed. The patient presented small complications fully solved throughout the postoperative care. At the 18th POD, he presented hemodynamic instability associated with tarry stools and hematic secretion in abdominal drains. He underwent emergency exploratory laparotomy. A large hemoperitoneum was identified as a result of bleeding in the left gastric artery stump, with closed hemolocks found close. It was possible to stop the bleeding, with improvement of hemodynamic parameters, which was not sustained, worsening the patient's condition and leading him to death. Discussion: Postoperative arterial hemorrhage is a possible complication of complex procedures, such as full gastrectomy with D2 lymphadenectomy, which occurs in 1.9 to 2.6% of cases and has a mortality rate close to 30%. It is classified into early postoperative arterial hemorrhage, which occurs within the first 24 hours after the procedure and late postoperative arterial hemorrhage, that occurs after this period, as in the reported case. Late postoperative arterial hemorrhage has two major etiologies: artery erosion due to primary complication and/or possible arterial wall injury during lymphadenectomy. The vessels most commonly affected in postoperative arterial hemorrhage after gastrectomy are derived from the coeliac trunk. There are risk factors for postoperative arterial hemorrhage, such as age > 70 years, male gender, BMI > 25, prolonged surgical time and resection of other organs. Patient with postoperative arterial hemorrhage after gastrectomy may present bright red massive bleeding in the abdominal drain and/or upper or lower gastrointestinal bleeding, with a hemoglobin drop, severe abdominal pain and hemodynamic instability. The treatment for late postoperative hemorrhage depends on the patient's diagnosis and hemodynamic status. It is possible to try an approach through interventional radiology or surgical approach. Final comments: Robotic oncologic surgeries are safe and effective, but not completely free of complications, as in the reported case, with a late postoperative arterial hemorrhage, which is rare but quite severe and complex to manage.

 

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Publication History

Article published online:
23 October 2019