Mechanisms of histopathologic vascular damage caused by pancreatic juice leakage: Implications for preventing hemorrhagic complications.

BACKGROUND

This study presents a prospective experimental analysis aimed to investigate the enzymatic interactions that cause histologic changes in the vascular wall to help prevent bleeding complications after pancreatic surgery. Severe hemorrhage can result from the accumulation of pancreatic juice and digestive fluids around vascular stumps. However, the specific digestive enzymes and their interactions that cause histologic damage to vascular walls remain unclear.

METHODS

Histopathologic changes in porcine arterial and venous walls were examined 48 hours after exposure to enzymatic solutions and human pancreatic juice, with or without a mixture of other digestive fluids obtained from 4 patients undergoing pancreatoduodenectomy. Moreover, the protective effect of a protease inhibitor added to active pancreatic juice against histopathologic damage was evaluated.

RESULTS

Thinning of the arterial walls, with degeneration of smooth muscle nuclei and muscle/collagen fibers in the media, was significant after exposure to trypsin or chymotrypsin, and, among human digestive fluids, only after exposure to pancreatic juice mixed with intestinal fluid. Venous walls were more vulnerable to proteases and digestive fluids. Histopathological changes in the arterial wall were prevented when 10 units of nafamostat mesylate (protease inhibitor) were added to the pancreatic juice mixed with intestinal fluid.

CONCLUSION

The activation of pancreatic proteases through mixing with intestinal fluids is a major factor causing histologic damage to the arterial media, leading to aneurysm formation and rupture of the vascular wall. Developing methods for the localized and continuous administration of protease inhibitors around vascular stumps could reduce life-threatening bleeding complications after pancreatic surgery.