Complications of Whipple Procedure

1. https://www.ncbi.nlm.nih.
gov/pubmed/27654839
Dig Surg. 2017;34(2):114-124. doi: 10.1159/000449105. Epub 2016 Sep 22.
Hemorrhagic and Thromboembolic Complications after

Hepato-Biliary-Pancreatic Surgery in Patients Receiving
Antithrombotic Therapy.
Ishida J1, Fukumoto T, Kido M, Matsumoto I, Ajiki T, Kawai H, Hirata K, Ku Y.
Author information
Abstract
BACKGROUND:
Perioperative management for patients receiving long-term anticoagulant (AC) and antiplatelet (AP)
therapy is a great concern for surgeons. This single-center retrospective study evaluated the risks of
hemorrhage and thromboembolism after hepato-biliary-pancreatic (HBP) surgery in such patients.
METHODS:
Between 2009 and 2014, 886 patients underwent HBP surgery. Patients were categorized into the
AC (n = 39), AP (n = 77), or control (n = 770) group according to the administration of antithrombotic
drugs. Perioperative management of AC and AP therapies followed the guidelines of the Japanese
Circulation Society. The incidences of hemorrhage and thromboembolism were compared among
groups. We used 1:1 propensity score matching and compared the incidences between the matched
pairs.
RESULTS:
There were 0, 1 (1.3%), and 26 (3.4%) hemorrhagic complications in the AC, AP, and control
groups, respectively (p = 0.16). There were 0, 1 (1.3%), and 6 (0.8%)
thromboembolic complications in the AC, AP, and control groups, respectively (p = 0.66). There was
no significant difference in hemorrhagic and thromboembolic complicationsbetween the propensity-
matched pairs.
CONCLUSION:
The incidences of hemorrhage and thromboembolism after HBP surgery in patients receiving long-
term AC and AP therapies are within acceptable ranges.
© 2016 S. Karger AG, Basel.

2. https://www.ncbi.nlm.nih.gov/pubmed/27321887
J Vasc Interv Radiol. 2017 Jan;28(1):50-59.e5. doi: 10.1016/j.jvir.2016.04.004. Epub 2016 Jun 16.
Endovascular Treatment of Hepatic Artery

Pseudoaneurysm after Pancreaticoduodenectomy: Risk
Factors Associated with Mortality and Complications.
Hasegawa T1, Ota H2, Matsuura T2, Seiji K2, Mugikura S2, Motoi F2, Unno M2, Takase K2.
Author information
Abstract
PURPOSE:
To evaluate risk factors predicting death and complications of primary therapy for hepatic and gastric
duodenal artery pseudoaneurysms following endovascular treatment (EVT)
after pancreaticoduodenectomy (PD).
MATERIALS AND METHODS:

Between April 2004 and December 2014, 28 patients (mean age, 64.7 y) with post-PD hemorrhage
underwent EVT. Prevention of hepatic artery blockage via stents or side-holed catheter grafts was
stratified in cases without a replaced hepatic artery. Mortality and major
hepatic complications following EVT were evaluated according to age; sex; surgery-EVT interval;
presence of portal vein stenosis, shock, and coagulopathy at EVT onset; and post-EVT angiographic
findings.
RESULTS:
All hemorrhages were successfully treated with microcoils (n = 17; 61%), covered stents (n = 1; 3%),
bare stent-assisted coil embolization (n = 5; 18%), or catheter grafts with coil embolization (n = 5;
18%). Hepatic arterial flow was observed after EVT in 18 patients (64%). Mortality and major hepatic
complication rates were 28.6% and 32.1%, respectively. Hemorrhagic shock and coagulopathy at
EVT onset (n = 8 each; odds ratio [OR], 27; 95% confidence interval [CI], 3.1-235.7; P < .01) were
significantly associated with mortality. Coagulopathy at EVT onset (adjusted OR [aOR], 48.1; 95%
CI, 3.2-2,931), portal vein stenosis (n = 16; aOR, 16.9; 95% CI, 1.3-721.9), and no visualization of
hepatopetal flow through the hepatic arteries (n = 10; aOR, 29.5; 95% CI, 2.1-1,477) were
significantly associated with major hepatic complications.
CONCLUSIONS:
EVT should be performed as soon as possible before the development of shock or coagulopathy.
Hepatic arterial flow visualization decreases major hepatic complications.
Hepatobiliary Pancreat Dis Int. 2014 Oct;13(5):513-22.
Post-pancreaticoduodenectomy hemorrhage: risk

factors, managements and outcomes.
Feng J1, Chen YL, Dong JH, Chen MY, Cai SW, Huang ZQ.
Author information
Abstract
BACKGROUND:
Post-pancreaticoduodenectomy (PD) hemorrhage (PPH) is an uncommon but serious complication.
This retrospective study analyzed the risk factors, managements and outcomes of the patients with
PPH.
METHODS:
A total of 840 patients with PD between 2000 and 2010 were retrospectively analyzed. Among them,
73 patients had PPH: 19 patients had early PPH and 54 had late PPH. The assessment included the
preoperative history of disease, pancreatic status and surgical techniques. Other
postoperative complications were also evaluated.
RESULTS:
The incidence of PPH was 8.7% (73/840). There were no independent risk factors for early PPH.
Male gender (OR=4.40, P=0.02), diameter of pancreatic duct (OR=0.64, P=0.01), end-to-side
invagination pancreaticojejunostomy (OR=5.65, P=0.01), pancreatic fistula (OR=2.33, P=0.04) and
intra-abdominal abscess (OR=12.19, P<0.01) were the independent risk factors for late PPH. Four
patients with early PPH received conservative treatment and 12 were treated surgically. As for
patients with late PPH, the success rate of medical therapy was 27.8% (15/54). Initial endoscopy
was operated in 12 patients (22.2%), initial angiography in 19 (35.2%), and relaparotomy in 15
(27.8%). Eventually, PPH resulted in 19 deaths. The main causes of death were multiple organ
failure, hemorrhagicshock, sepsis and uncontrolled rebleeding.
CONCLUSIONS:
Careful and ongoing observation of hemorrhagic signs, especially within the first 24 hours after PD
or within the course of pancreatic fistula or intra-abdominal abscess, is recommended for patients
with PD and a prompt management is necessary. Although endoscopy and angiography are the
standard procedures for the management of PPH, surgical approach is still irreplaceable. Aggressive
prevention of hemorrhagic shock and re-hemorrhage is the key to treat PPH.
Hepatogastroenterology. 2013 May;60(123):425-7.
Heterotopic pancreas autotransplantation with spleen for

uncontrollable hemorrhagic pseudocyst and disabling
pain in chronic pancreatitis.
Sato Y1, Oya H, Yamamoto S, Kokai H, Miura K, Hatakeyama K.
Author information
Abstract
BACKGROUND/AIMS:
In this study, we report on a heterotopic segmental pancreatic autotransplantation (HPAT) with
spleen for alcoholic chronic pancreatitis with uncontrollable hemorrhagic pseudocyst and complete
portal venous obstruction. The patient was a 72-year-old man who had an alcoholic chronic
pancreatitis with severe abdominal pain and hemorrhagic pseudocyst. The first bleeding from a
pseudoaneurism of the gastro-duodenal artery (GDA) to the cyst of pancreas head was stopped by
interventional radiology (IVR) at our hospital on May 2010. The second bleeding happened with
severe abdominal pain on February 15th, 2011; he was admitted on February 17. The IVR was not
successful.
METHODOLOGY:
There were two problems for the operation. The first was the severe inflammation and the second
was the control of hemorrhage from GDA. We were afraid of the postoperative hemorrhage due to
the leakage of pancreatic juice in the pancreato-duodenectomy (PD). Therefore, we chose the HPAT
as a solution for postoperative hemorrhage and severe abdominal pain. After complete duodeno-
pancreatectomy with spleen, we performed HPAT with spleen on March 8, 2011. The pancreatic
duct reconstruction was performed by Roux-en-Y anastomosis to the jejunum.
RESULTS:
The postoperative course was uneventful. The abdominal pain had resolved completely and the
patient remained normoglycemic after HPAT.
CONCLUSIONS:
We conclude that HPAT is a useful option for hemorrhagic pseudocyst of the pancreas head with
severe abdominal pain of chronic pancreatitis.
AJR Am J Roentgenol. 2011 Jan;196(1):192-7. doi: 10.2214/AJR.10.4727.
Hemorrhagic complications after Whipple surgery:

imaging and radiologic intervention.
Puppala S1, Patel J, McPherson S, Nicholson A, Kessel D.
Author information
Abstract
OBJECTIVE:
The aim of this pictorial essay is to illustrate the radiologic patterns, sites of bleeding, and vascular
interventional techniques used in the management of postpancreatectomy hemorrhage.
CONCLUSION:
Hemorrhagic complications occur in fewer than 10% of patients
after Whipple pancreatoduodenectomy but account for as many as 38% of deaths. Bleeding typically
occurs from the stump of the gastroduodenal artery, but other sites of bleeding are increasingly
recognized.
JOP. 2009 Jul 6;10(4):441-4.
Pseudoaneurysmal rupture of the common hepatic artery

into the biliodigestive anastomosis. A rare cause of
gastrointestinal bleeding.
Vernadakis S1, Christodoulou E, Treckmann J, Saner F, Paul A, Mathe Z.
Author information
Abstract
CONTEXT:
Pseudoaneurysm of the hepatic artery after a pancreaticoduodenectomy is a serious complication,
which should always be considered in the differential diagnosis when late bleeding has occurred.
CASE REPORT:
We report a case of pseudoaneurysmal rupture of the common hepatic artery into the biliodigestive
anastomosis. A 55 year old female patient with a history of pancreatic head cancer underwent a
pylorus preserving pancreaticoduodenectomy at our hospital in September 2008. Six days
postoperatively the patient underwent surgery because of sentinel bleeding of a portal vein branch.
On the 40th postoperative day she presented melena. Upper gastrointestinal endoscopy indicated
bleeding near the biliodigestive anastomosis. An emergency angiography demonstrated a
pseudoaneurysm of the common hepatic artery. Transcatheter arterial embolization was performed
and a hemodynamic stabilization of the patient was achieved. Six days after the embolization the
patient developed hemorrhagic shock and an urgent relaparotomy was carried out. The explorative
laparotomy revealed bleeding of the common hepatic artery into the biliodigestive anastomosis in the
form of an arteriointestinal fistula. The anastomosis was opened, the ruptured pseudoaneurysm was
sutured, and a new biliodigestive anastomosis was made. The patient has been well for two months
with good liver function, without rebleeding.
CONCLUSION:
This case illustrates the occurrence of a rare complication (rupture of a hepatic artery
pseudoaneurysm) inside the biliodigestive anastomosis after pancreaticoduodenectomy, appearing
as upper gastrointestinal bleeding. Different modalities such as transarterial embolization and the
use of stents give promising results, but ligation of the pseudoaneurysm and repair of the intestinal
communication is also an effective modality of treatment.
7. https://www.ajronline.org/doi/full/10.2214/AJR.10.4727
Hemorrhagic Complications After Whipple Surgery: Imaging
and Radiologic Intervention
OBJECTIVE. The aim of this pictorial essay is to illustrate the radiologic patterns, sites of bleeding,
and vascular interventional techniques used in the management of postpancreatectomy
hemorrhage.
CONCLUSION. Hemorrhagic complications occur in fewer than 10% of patients after Whipple
pancreatoduodenectomy but account for as many as 38% of deaths. Bleeding typically occurs from
the stump of the gastroduodenal artery, but other sites of bleeding are increasingly recognized.
Keywords: CT angiography, digital subtraction angiography, embolization, pancreatoduodenectomy, stent

8. https://link.springer.com/article/10.1007/s00534-008-0012-3
Management of postoperative arterial hemorrhage after pancreato-biliary
surgery according to the site of bleeding: re-laparotomy or interventional
radiology
Background/Purpose
Intra-abdominal arterial hemorrhage is still one of the most serious complications after
pancreato-biliary surgery. We retrospectively analyzed our experiences with 15 patients in order
to establish a therapeutic strategy for postoperative arterial hemorrhage following pancreato-
biliary surgery.
Methods
Between August 1981 and November 2007, 15 patients developed massive intra-abdominal
arterial bleeding after pancreato-biliary surgery. The initial surgery of these 15 patients were
pylorus-preserving pancreatoduodenectomy (PPPD) (7 patients), hemihepatectomy and caudate
lobectomy with extrahepatic bile duct resection or PPPD (4 patients), Whipple’s
pancreatoduodenectomy (PD) (3 patients), and total pancreatectomy (1 patient). Twelve patients
were managed by transcatheter arterial embolization and three patients underwent re-laparotomy.
Results
Patients were divided into two groups according to the site of bleeding: SMA group, superior
mesenteric artery (4 patients); HA group, stump of gastroduodenal artery, right hepatic artery,
common hepatic artery, or proper hepatic artery (11 patients). In the SMA group, re-laparotomy
and coil embolization for pseudoaneurysm were performed in three and one patients,
respectively, but none of the patients survived. In the HA group, all 11 patients were managed by
transcatheter arterial embolization. None of four patients who had major hepatectomy with
extrahepatic bile duct resection survived. Six of seven patients (85.7%) who had pancreatectomy
survived, although hepatic infarction occurred in four.
Conclusions
Management of postoperative arterial hemorrhage after pancreato-biliary surgery should be done

according to the site of bleeding and the initial operative procedure. Careful consideration is
required for indication of interventional radiology for bleeding from SMA after pancreatectomy and
hepatic artery after major hepatectomy with bilioenteric anastomosis.
Post-pancreaticoduodenectomy Hemorrhage.
Incidence, Diagnosis, and Treatment
Background
Although mortality post-pancreaticoduodenectomy (PD) has decreased, morbidity rates continue

to be high, ranging from 30% to 50%. Among complications, hemorrhage stands out; it is
associated with high mortality and there is no standard management. The aim of the present
study was to analyze the incidence, diagnosis, and treatment of hemorrhage post-cephalic PD at
our center.
Methods
From January 2005 to December 2008, 107 PDs were performed. A retrospective review of
characteristics of patients with postoperative hemorrhage was made from our prospective
database. Demographic data, diagnosis, treatment (medical, laparotomy, interventional
radiology), association with fistula (pancreatic or biliary), intra- or extraluminal hemorrhage,
bleeding time (early or late), severity (moderate/severe), and mortality were analyzed.
Results
Eighteen patients (18/107; 16.82%) hemorrhaged after PD. Hemorrhage appeared early (< 24 h)
in 4 of these 18 patients (22.2%), and it was severe in 13/18 (72%). Hemorrhage-related
mortality was 11% (2/18) and hospital mortality was 22.2% (4/18). Arteriography was performed
in 8/18 patients (44.4%) and was effective in 6/8 (75%); laparotomy was performed in 8/18
(44.4%). Re-bleeding occurred in 5 of these 18 patients after the first treatment (27.8%). An
association between hemorrhage and fistula was observed.
Conclusions
Hemorrhage after pancreatic resection must be considered a complication with relatively high
mortality. Diagnosis should be established and treatment applied rapidly. Pancreatic and/or
biliary fistulae were significantly associated with a higher risk of postoperative hemorrhage.
Interventional radiology is a good therapeutic option.
Systematic Review of Delayed Postoperative Hemorrhage after

Pancreatic Resection
Introduction
This review assesses the presentation, management, and outcome of delayed
postpancreatectomy hemorrhage (PPH) and suggests a novel algorithm as possible
standard of care.
Methods
An electronic search of Medline and Embase databases from January 1990 to February
2010 was undertaken. A random-effect meta-analysis for success rate and mortality of
laparotomy vs. interventional radiology after delayed PPH was performed.
Results
Fifteen studies comprising of 248 patients with delayed PPH were included. Its
incidence was of 3.3%. A sentinel bleed heralding a delayed PPH was observed in 45%
of cases. Pancreatic leaks or intraabdominal abscesses were found in 62%.
Interventional radiology was attempted in 41%, and laparotomy was undertaken in
49%. On meta-analysis comparing laparotomy vs. interventional radiology, no
significant difference could be found in terms of complete hemostasis (76% vs.
80%; P = 0.35). A statistically significant difference favored interventional radiology
vs. laparotomy in term of mortality (22% vs. 47%; P = 0.02).
Conclusions
Proper management of postoperative complications, such as pancreatic leak and
intraabdominal abscess, minimizes the risk of delayed PPH. Sentinel bleeding needs to
be thoroughly investigated. If a pseudoaneurysm is detected, it has to be treated by
interventional angiography, in order to prevent a further delayed PPH. Early
angiography and embolization or stenting is safe and should be the procedure of
choice. Surgery remains a therapeutic option if no interventional radiology is available,
or patients cannot be resuscitated for an interventional treatment.
11. http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.503.9551&rep=rep1&type=pdf
12. https://www.sciencedirect.com/science/article/pii/S1499387214602769
Post-pancreaticoduodenectomy hemorrhage risk factors, managements and
outcomes
Background
Post-pancreaticoduodenectomy (PD) hemorrhage (PPH) is an uncommon but serious complication. This

retrospective study analyzed the risk factors, managements and outcomes of the patients with PPH.
Methods
A total of 840 patients with PD between 2000 and 2010 were retrospectively analyzed. Among them, 73 patients had
PPH: 19 patients had early PPH and 54 had late PPH. The assessment included the preoperative history of disease,
pancreatic status and surgical techniques. Other postoperative complications were also evaluated.
Results
The incidence of PPH was 8.7% (73/840). There were no independent risk factors for early PPH. Male gender
(OR=4.40, P=0.02), diameter of pancreatic duct (OR=0.64, P=0.01), end-to-side invagination
pancreaticojejunostomy (OR=5.65, P=0.01), pancreatic fistula (OR=2.33, P=0.04) and intra-abdominal abscess
(OR=12.19, P<0.01) were the independent risk factors for late PPH. Four patients with early PPH received
conservative treatment and 12 were treated surgically. As for patients with late PPH, the success rate of medical
therapy was 27.8% (15/54). Initial endoscopy was operated in 12 patients (22.2%), initial angiography in 19
(35.2%), and relaparotomy in 15 (27.8%). Eventually, PPH resulted in 19 deaths. The main causes of death were
multiple organ failure, hemorrhagic shock, sepsis and uncontrolled rebleeding.
Conclusions
Careful and ongoing observation of hemorrhagic signs, especially within the first 24 hours after PD or within the
course of pancreatic fistula or intra-abdominal abscess, is recommended for patients with PD and a prompt
management is necessary. Although endoscopy and angiography are the standard procedures for the management of
PPH, surgical approach is still irreplaceable. Aggressive prevention of hemorrhagic shock and re-hemorrhage is the
key to treat PPH.
13. https://journals.lww.com/cmj/Fulltext/2012/05010/Factors_associated_with.9.aspx
Factors associated with post-pancreaticoduodenectomyhemorrhage: 303 consecutive cases analysis
Background Because of the complexity and severity of the surgery and its associated
complications, pancreaticoduodenectomy (PD) is associated with significant morbidity and mortality, especially the
hemorrhage post-PD. Exploring the factors associated with post-PD hemorrhage is very important for the patients'
safety.
Methods Clinical data from 303 cases of PD between January 1998 and December 2008 were analyzed
retrospectively.
Results The overall mortality rate was 4.95% (15/303). However, post-operative bleeding occurred in 25 patients
(8.25%) with nine episodes resulting in death (36.00%). Univariate analysis was performed and identified tumor
size, Child's classification, total pancreatic uncinatic process resection, and pancreatic leakage as significant risk
factors for post-PD hemorrhage. In the severe hemorrhage group, incomplete resection of uncinate process of
pancreas and pancreatic leakage were the main causes. The multivariate Logistic regression analysis revealed that
each of these variables is an independent risk factor.
Conclusions Primary prevention of bleeding complications depends on total pancreatic uncinatic process resection
and meticulous hemostatic techniques during surgery. In addition, several peri-operative factors were found to
contribute to post-PD bleeding.
14. https://journals.sagepub.com/doi/full/10.1177/1457496916631854
Hemorrhage after Major Pancreatic Resection: Incidence, Risk
Factors, Management, and Outcome
Background and Aims:
Hemorrhage is a rare but dreaded complication after pancreatic surgery. The aim of this study was to examine the
incidence, risk factors, management, and outcome of postpancreatectomy hemorrhage in a tertiary care center.
Materials and Methods:
A retrospective observational study was conducted on 500 consecutive patients undergoing major pancreatic
resections at our institution. Postpancreatectomy hemorrhage was defined according to the International Study
Group of Pancreatic Surgery criteria.
Results:
A total of 68 patients (13.6%) developed postpancreatectomy hemorrhage. Thirty-four patients (6.8%) had a type A,
15 patients (3.0%) had a type B, and the remaining 19 patients (3.8%) had a type C bleed. Postoperative pancreatic
fistula Grades B and C and bile leakage were significantly associated with severe postpancreatectomy hemorrhage
on multivariable logistic regression. For patients with postpancreatectomy hemorrhage Grade C, the onset of
bleeding was in median 13 days after the index operation, ranging from 1 to 85 days. Twelve patients (63.2%) had
sentinel bleeds. Surgery lead to definitive hemostatic control in six of eight patients (75.0%). Angiography was able
to localize the bleeding source in 8/10 (80.0%) cases. The success rate of angiographic hemostasis was 8/8.
(100.0%). The mortality rate among patients with postpancreatectomy hemorrhage Grade C was 2/19 (10.5%), and
both fatalities occurred late as a consequence of eroded vessels in association with pancreaticogastrostomy.
Conclusion:
Delayed hemorrhage is a serious complication after major pancreatic surgery.Sentinel bleed is an early warning sign.
Postoperative pancreatic fistula and bile leakage are important risk factors for severe postpancreatectomy
hemorrhage.
15.
https://www.ncbi.nlm.nih.gov/pubmed?term=Hemorrhagic%20Complications%20of%20Whipple%20Procedure%2
Fpancreaticiduodenotomy
Sentinel bleeding after pancreaticoduodenectomy: a

disregarded sign.
Treckmann J1, Paul A, Sotiropoulos GC, Lang H, Ozcelik A, Saner F, Broelsch CE.
Author information
Abstract
INTRODUCTION:
Delayed massive hemorrhage induced by pancreatic fistula after pancreaticoduodenectomy is a rare
but life-threatening complication. The purpose of this study was to analyze the clinical course of
patients with late hemorrhage, with or without sentinel bleeding, to better define treatment options in
the future.
MATERIAL AND METHODS:

From April 1998 to December 2006, 189 pancreaticoduodenectomies were performed. Eleven
patients, including two patients referred from other hospitals, were treated with delayed massive
hemorrhage occurring 5 days or more after pancreaticoduodenectomy. Sentinel bleeding was
defined as minor blood loss via surgical drains or the gastrointestinal tract with an asymptomatic
interval until development of hemorrhagic shock. The clinical data of patients with bleeding episodes
were analyzed retrospectively.
RESULTS:
Eight of the 11 patients had sentinel bleeding, and seven of them had it at least 6 h before acute
deterioration. Seven out of 11 patients died, five out of eight with sentinel bleeding. No differences
could be detected between patients with or without sentinel bleeding before delayed massive
hemorrhage. The only difference found was that non-surviving patients were significantly older than
surviving patients. Delayed massive hemorrhage is a common cause of death
after pancreaticoduodenostomy complicated by pancreatic fistula formation. The observation of
sentinel bleeding should lead to emergency angiography and dependent from the result to
emergency relaparotomy to increase the likelihood of survival.
Delayed hemorrhage after pancreaticoduodenectomy.
Choi SH1, Moon HJ, Heo JS, Joh JW, Kim YI.
Author information
Abstract
BACKGROUND:
Postoperative hemorrhage, particularly delayed hemorrhage after pancreaticoduodenectomy, is a
serious complication and one of the most common causes of mortality
after pancreaticoduodenectomy.
STUDY DESIGN:
The medical records of 500 patients who underwent pancreaticoduodenectomy between October
1994 and December 2002 were analyzed with regard to postoperative hemorrhagic complications.
Delayed hemorrhage was defined as bleeding at the operation site after 5 or more postoperative
days.
RESULTS:
Delayed hemorrhage occurred in 22 patients (4.4%), with a median time of 13 days (range 7 to 32
days) after pancreaticoduodenectomy, and developed more frequently (9/77 versus 13/423, p =
0.003) in patients with preceding intraabdominal complications such as pancreatic fistula, bile fistula,
and intraabdominal abscess. In 17 of these 22 patients, angiography and laparotomy revealed
bleeding foci at 14 arterial and 3 anastomotic sites. In nine patients, hemorrhage developed from
pseudoaneurysms of the major arteries around the pancreaticojejunostomy. Hemostatis was
attempted by transcatheter arterial embolization in 14 patients and with laparotomy in 4 patients.
Four of 14 patients who received transcatheter arterial embolization eventually required laparotomy.
Overall, 4 of the 22 delayed hemorrhage patients died (18.2%) of complications related to massive
bleeding or transcatheter arterial embolization.
CONCLUSIONS:
Delayed hemorrhage after pancreaticoduodenectomy is associated with a high mortality.
Intraabdominal complications after pancreaticoduodenectomy should be evaluated properly and
guidelines for the diagnosis and treatment of delayed hemorrhage should be established in advance.
Clinicians must be alert to the possibility of pseudoaneurysm hemorrhage.
Zhonghua Yi Xue Za Zhi. 2012 Apr 24;92(16):1119-21.
[Delayed massive hemorrhage

after pancreaticoduodenectomy].
[Article in Chinese]
Meng XF1, Wang J, Wang ZJ, Huang XQ, Xia HT, Dong JH.
Author information
1
Department of Hepatobiliary Surgery, PLA General Hospital, Beijing 100853 China.
Abstract
OBJECTIVE:
To summarize our clinical experiences of delayed massive hemorrhage (DMH), a rare but fatal
complication, after pancreaticoduodenectomy (PD).
METHODS:
The clinical data of 14 DMH patients at our medical center were collected and analyzed to evaluate
the risk factors and to compare the efficacies of different therapies.
RESULTS:
A total of 1008 PD patients were treated since April 1993. Fourteen DMHs occurred post-operatively
(1.4%). In these cases, 10/14 (71.4%) were complicated with pancreatic fistula. Sentinel bleeding
was observed in 10 (71.4%) cases. The clinical manifestations of DMH included simple abdominal
hemorrhage (n = 6, 42.9%), alimentary tract hemorrhage (n = 6, 42.9%) and both (n = 3, 21.4%).
Shock (n = 2, 14.3%) might also be the initial symptom. Thirteen cases achieved post-therapeutic
hemostasis while 1 patient died before re-admission. The therapeutic modalities included
interventional therapy (n = 8) and surgery (n = 5). According to the therapeutic modalities, the re-
bleeding rate, morbidity and final mortality of two groups were 50.0% vs 40.0% (P = 0.83), 75.0% vs
60.0% (P = 0.96) and 50.0% vs 80.0% (P = 0.62) respectively. Five patients survived at the end of
treatment. The mortality rate was 71.4%.
CONCLUSION:
As a rare but fatal complication after PD, DMH is difficult to diagnose and treat. Postoperative
pancreatic fistula remains a possible but undetermined risk factor. Sentinel bleeding is of great
predicative value for DMH. Regular interventional arteriography is an effective method of improving
diagnosis and treatment. Both interventional therapy and surgery may be used to treat DMH.
Ann Surg Oncol. 2008 Jul;15(7):1855-61. doi: 10.1245/s10434-008-9894-1. Epub 2008 Apr 16.
Angiography is indicated for every sentinel bleed

Tien YW 1, Wu YM, Liu KL, Ho CM, Lee PH.
Author information
Abstract
BACKGROUND:
Delayed massive bleeding is one of the leading causes of mortality
after pancreaticoduodenectomy(PD) and is often preceded by sentinel bleed. Immediate and
accurate diagnosis of sentinel bleed is essential to save patients from a delayed massive
hemorrhage. Angiography is probably the procedure of choice for patients with sentinel bleed after
PD, as it will localize the bleeding point and provide interventional embolization. The purpose of this
study is to test the efficiency of angiography as the initial management for patients with sentinel
bleed after pancreaticoduodenectomy.
METHODS:
The study group consisted of 283 patients who underwent PD from July 2002 to June 2007.
Angiography and arterial embolization were performed for every sentinel bleed and detected
pseudoaneurysm. Patients (n = 311) from a previous study (July 1996-June 2002) were used as a
historical control group.
RESULTS:
Sentinel bleed was detected in 20 patients in study group. Of these, angiography-detected
pseudoaneurysm was evident in seven (35%); all were successfully embolized. Delayed massive
hemorrhage occurred in three of 13 patients with sentinel bleed but negative angiography. All three
were operated on; one died of uncontrolled bleeding. The number of hemodynamically unstable
patients before transfusion, units of transfused packed cells, and bleeding related mortalities were
significantly less in study group than the control group.
CONCLUSIONS:
Institution of angiography for every detected sentinel bleed after PD enabled us to embolize seven
pseudoaneurysms before massive hemorrhage. Most importantly, bleeding-related mortality was
significantly less than in the absence of angiography.
Arch Surg. 2008 Oct;143(10):1001-7; discussion 1007. doi: 10.1001/archsurg.143.10.1001.
Management of delayed postoperative hemorrhage

after pancreaticoduodenectomy: a meta-analysis.
Limongelli P1, Khorsandi SE, Pai M, Jackson JE, Tait P, Tierris J, Habib NA, Williamson RC, Jiao
LR.
Author information
Abstract
OBJECTIVE:
To determine whether interventional radiology (IR) or laparotomy (LAP) is the best management of
delayed postoperative hemorrhage (DPH) after pancreaticoduodenectomy. Data Source We
undertook an electronic search of MEDLINE and selected for analysis only original articles published
between January 1, 1990, and December 31, 2007.
STUDY SELECTION:
Two of us independently selected studies reporting on clinical presentation and incidence of
postoperative DPH and the following outcomes: complete hemostasis, morbidity, and mortality.
DATA EXTRACTION:
Two of us independently performed data extraction. Data were entered and analyzed by means of
dedicated software from The Cochrane Collaboration. A random-effects meta-analytical technique
was used for analysis.
DATA SYNTHESIS:
One hundred sixty-three cases of DPH after pancreaticoduodenectomy were identified from the
literature. The incidence of DPH after pancreaticoduodenectomy was 3.9%. Seventy-seven patients
(47.2%) underwent LAP; 73 (44.8%), IR; and 13 (8%), conservative treatment. On meta-analysis
comparing LAP vs IR for DPH, no significant difference was found between the 2 treatment options
for complete hemostasis (73% vs 76%; P = .23), mortality (43% vs 20%; P = .14), or morbidity (77%
vs 35%; P = .06).
CONCLUSIONS:
This meta-analysis, although based on data from small case series, is unable to demonstrate any
significant difference between LAP and IR in the management of DPH after pancreaticoduodenectomy.
The management of this life-threatening complication is difficult, and the appropriate treatment pathway
ultimately will be decided by the clinical status of the patient and the institution preference .
World J Surg. 2015 Feb;39(2):509-15. doi: 10.1007/s00268-014-2809-3.
Diagnostic and therapeutic strategies to manage post-

pancreaticoduodenectomyhemorrhage.
Chen JF1, Xu SF, Zhao W, Tian YH, Gong L, Yuan WS, Dong JH.
Author information
Abstract
OBJECTIVE:
To explore the causes, diagnosis and treatment of post-pancreaticoduodenectomy hemorrhages
(PPHs).
METHODS:
A database of 703 pancreaticoduodenectomy patients in our institution (January 2008-July 2013)
was analyzed retrospectively.
RESULTS:
PPHs occurred in 62 patients of which, 38 had clear causes and 15 died because of uncontrolled
bleeding and multiple organ failure. Pancreatic fistula and abdominal infection rates were
significantly higher in the PPH group compared to the group who did not experience hemorrhages (P
< 0.05) but did not significantly increase the mortality of PPH patients. Hemostasis was attempted by
endotherapy in 7 patients and was successful in 4 (57.1 %). Angioembolization was performed in 12
patients and was successful in 10 (83.3 %) and relaparotomy in 24 patients successful in 13 (54.2
%). All deceased patients belonged to International Study Group of Pancreatic Surgery clinical grade
C and sentinel bleeding occurred in 60 % of PPH mortalities (9/15) (P = 0.005).
CONCLUSION:
Pancreatic fistulae and abdominal infections are associated with PPH. Control of early mild upper
gastrointestinal hemorrhages could be attempted by endotherapy, but angiography with intervention
or surgical treatments were always required for delayed bleeding. The mortality in cases with
sentinel bleedings was obviously increased.
J Gastrointest Surg. 2009 May;13(5):922-8. doi: 10.1007/s11605-009-0818-6. Epub 2009 Feb 18.
Results of non-operative therapy for delayed hemorrhage

Beyer L1, Bonmardion R, Marciano S, Hartung O, Ramis O, Chabert L, Léone M, Emungania
O, Orsoni P, Barthet M, Berdah SV, Brunet C, Moutardier V.
Author information
Abstract
INTRODUCTION:
Hemorrhage after pancreaticoduodenectomy is a life-threatening complication, which occurs in 4%
to 16% of cases, even in experienced centers. Many diagnostic and therapeutic options exist but no
one has yet established management guidelines. This study aimed to determine the role of
conservative management in delayed hemorrhage.
PATIENTS AND METHODS:

From January 2005 to August 2008, 87 patients underwent pancreaticoduodenectomy at our center.
We reviewed, retrospectively, the medical charts of all patients who had experienced postoperative
hemorrhage.
RESULTS AND DISCUSSION:

Early hemorrhage occurred in one patient, who underwent successful reoperation. Nine patients
presented with delayed hemorrhage (10.3%), including three with sentinel bleeding. Mean onset was
20 days post-surgery. We used the same initial management for each patient: all had an urgent
contrast computed tomography scan. In every case, the bleeding site was arterial. Conservative
treatment (embolization or covered stent) was successful in every case. We reoperated on two
patients for gastrointestinal perforation, at 9 days and 2 months after embolization, respectively. We
transferred seven patients to an intensive care unit, with an average stay of 8 days. Mean hospital
stay was 43 days (33-60). All patients survived.
CONCLUSION:
Conservative management, combining endovascular procedures and aggressive resuscitation, is
appropriate for most cases of delayed hemorrhage after pancreaticoduodenectomy.
Hepatogastroenterology. 2003 Nov-Dec;50(54):2199-204.
Delayed massive arterial hemorrhage

after pancreaticoduodenectomy for cancer. Management
of a life-threatening complication.
Santoro R1, Carlini M, Carboni F, Nicolas C, Santoro E.
Author information
Abstract
BACKGROUND/AIMS:
Delayed massive arterial hemorrhage from the operating field occurs in 1-4% of cases
after pancreaticoduodenectomy, with a mortality rate up to 50%. The purpose of this study was to
define diagnostic and treatment methodologies to maximize survival.
METHODOLOGY:
Between 1990 and 1999, 84 pancreaticoduodenectomies were performed for periampullary and
pancreatic head cancer. After surgery, massive bleeding occurred in two patients (2.3%), 30 and 8
days after resection, respectively.
RESULTS:
Pancreatic leak and disruption of the pancreaticojejunostomy were reported in both cases. Bleeding
was controlled by suture ligation of the stump of the gastroduodenal artery. Completion
pancreatectomy and a new pancreaticojejunostomy were respectively performed. Hemorrhage
recurred in both cases from a ruptured pseudoaneurysm of the hepatic artery, requiring re-
exploration and surgical ligation. The first patient died of re-bleeding despite completion
pancreatectomy, the other survived after oversewing the residual pancreatic stump at re-exploration.
CONCLUSIONS:
Early diagnosis and management of pancreatic leak represents the only means to prevent a delayed
massive arterial hemorrhage. Transarterial embolization or surgical ligation of the hepatic artery
proximal to the celiac axis represents the procedure of choice to control the bleeding. Taking down
the pancreatic anastomosis and oversewing the pancreatic stump is safe and effective. Extensive
drainage of the operating field should always be associated to prevent multisystem organ failure.
JOP. 2012 Mar 10;13(2):193-8.
Late postpancreatectomy hemorrhage

after pancreaticoduodenectomy: is it possible to
recognize risk factors?
Ricci C1, Casadei R, Buscemi S, Minni F.
Author information
Abstract
CONTEXT:
Post-pancreatectomy hemorrhage is one of the most
common complications after pancreaticoduodenectomy.
OBJECTIVE:
To evaluate the late post-pancreatectomy hemorrhage rate according to the International Study
Group of Pancreatic Surgery criteria and to recognize factors related to its onset.
METHODS:
A prospective study of 113 patients who underwent pancreaticoduodenectomy was conducted. Late
post-pancreatectomy hemorrhage was defined according to the criteria of the International Study
Group of Pancreatic Surgery. Demographic, clinical, surgical and pathological data were considered
and related to late post-pancreatectomy hemorrhage.
RESULTS:
Thirty-one (27.4%) patients had a post-pancreatectomy hemorrhage. Twenty-five (22.1%) patients
developed late post-pancreatectomy hemorrhage: 19 (16.8%) grade B, 6 (5.3%) grade C. Surgical
re-operation was performed in 2 out of the 25 cases with late post-pancreatectomy hemorrhage
(8.0%) grade C associated with postoperative pancreatic fistula. At univariate analysis, the only
factor significantly related to late post-pancreatectomy hemorrhage was postoperative pancreatic
fistula (P<0.001). Multivariate analysis underlined that the severity of postoperative pancreatic fistula
(P<0.001) and pancreatic anastomosis (P=0.049) independently increased the risk of late
hemorrhage.
CONCLUSION:
In patients undergoing pancreaticoduodenectomy, the criteria introduced by International Study
Group of Pancreatic Surgery to define late postpancreatectomy hemorrhage are related to a higher
incidence of hemorrhage than previously detected because they considered also mild hemorrhage.
Am J Surg. 2007 Jul;194(1):3-9.
Hemorrhage after pancreaticoduodenectomy: when is

surgery still indicated?
Blanc T1, Cortes A, Goere D, Sibert A, Pessaux P, Belghiti J, Sauvanet A.
Author information
Abstract
BACKGROUND:
This study analyzed presentation and management of hemorrhage
after pancreaticoduodenectomy(PD) to determine the respective role of surgery and embolization.
METHODS:
From January 1992 to March 2005, 411 patients underwent PD and were analyzed with regard to
postoperative hemorrhage.
RESULTS:
Hemorrhage occurred in 27 patients (7%), either within the first 3 postoperative days ("early"
hemorrhage, n = 11) or after day 8 ("delayed" hemorrhage, n = 16, including 4 with "sentinel"
bleeding). At the time of bleeding, 12 patients (44%) (all with delayed hemorrhage) had associated
abdominal complications. Two patients had successful conservative treatment. Two stable patients
with pseudoaneurysm, diagnosed by computed tomography scan, underwent successful
embolization. Four patients with active bleeding underwent unsuccessful angiography. Overall, 23
patients were reoperated on without any completion pancreatectomy, 3 rebled, and 3 (11%) died
(including 2 with delayed hemorrhage).
CONCLUSIONS:
Both embolization and surgery have a role in the management of hemorrhage after PD. For early
hemorrhage, reoperation is appropriate. In case of sentinel bleeding, pseudoaneurysms can be
detected by computed tomography scan and treated by embolization. For delayed active
hemorrhage, reoperation is still indicated
JOP. 2009 Sep 4;10(5):492-5.
Pancreatic leak related hemorrhage

following pancreaticoduodenectomy. A case series.
Tsirlis T1, Vasiliades G, Koliopanos A, Kopanakis N, Katseli A, Tsipras H, Margaris H.
Author information
Abstract
CONTEXT:
Delayed arterial hemorrhage, secondary to pancreaticojejunal leakage, is an infrequent complication
(2-4%) of pancreaticoduodenectomy but it carries a high mortality rate with more than half of the
patients dying from overwhelming sepsis and/or bleeding. Its ideal management remains unclear.
CASE REPORTS:
We hereby present our experience with respect to the presentation and management of this severe
post-pancreaticoduodenectomy complication which occurred in 3/149 patients (2.1%) operated on
between 1996 and 2008 in our department and we review the role of endoscopy, interventional
radiology and surgery in its management.
CONCLUSIONS:
The severity of the underlying sepsis and the prompt identification of the sentinel bleed determine
surgical and angiographic intervention and define the outcome in the treatment of a pancreatic leak-
related hemorrhage. Endoscopy has no role in this setting.
World J Surg. 2014 Sep;38(9):2438-47. doi: 10.1007/s00268-014-2593-0.
Emergency management in patients with late hemorrhage

after pancreatoduodenectomy for a periampullary tumor.
Jilesen AP1, Tol JA, Busch OR, van Delden OM, van Gulik TM, Nieveen van Dijkum EJ, Gouma
DJ.
Author information
Abstract
BACKGROUND:
The mortality rate due to late hemorrhage after surgery for periampullary tumors is high, especially in
patients with anastomotic leakage. Patients usually require emergency intervention for late
hemorrhage. In this study patients with late hemorrhage and their outcomes were analyzed.
Furthermore, independent predictors for late hemorrhage, the need for emergency intervention, and
type of intervention are reported.
METHODS:
From a prospective database that includes 1,035 patients who underwent pancreatoduodenectomy
for periampullary tumors between 1992 and 2012, patients with late hemorrhage (>24 h after index
operation) were identified. Patient, disease-specific, and operation characteristics, type of
intervention, and outcomes were analyzed. Emergency intervention was defined as surgical or
radiological intervention in hemodynamically unstable patients.
RESULTS:
Of the 47 patients (4.5 %) with late hemorrhage, pancreatic fistula was an independent predictor for
developing late hemorrhage (OR 10.2). The mortality rate in patients with late hemorrhage was 13 %
compared with 1.5 % in all patients without late hemorrhage. Twenty patients required emergency
intervention; 80 % underwent primary radiological intervention and 20 % primary surgical
intervention. Extraluminal location of the bleeding (OR 5.6) and occurrence of a sentinel bleed (OR
6.6) are indications for emergency intervention.
CONCLUSION:
The type of emergency intervention needed for late hemorrhage is unpredictable. Radiological
intervention is preferred, but if it fails, immediate change to surgical treatment is mandatory. This can
be difficult to manage but possible when both radiological and surgical interventions are in close
proximity such as in a hybrid operating room and should be considered in the emergency
management of patients with late hemorrhage.
Int Surg. 2014 Jul-Aug;99(4):432-7. doi: 10.9738/INTSURG-D-13-00085.1.
Delayed arterial hemorrhage

Suzumura K1, Kuroda N, Kosaka H, Iimuro Y, Hirano T, Fujimoto J.
Author information
Abstract
Delayed arterial hemorrhage is a rare complication of pancreaticoduodenectomy that is associated

with a high mortality and has no standard management. Between 2000 and 2011, 204
pancreaticoduodenectomies were performed, and there were 3 cases of delayed arterial
hemorrhage. We reviewed the role of endoscopy, laparotomy, and interventional radiology the
management of delayed hemorrhage. One patient presented with intraluminal bleeding and upper
gastrointestinal endoscopy failed to identify the bleeding site. Two patients presented with bleeding
from the drain tube. Laparotomy was performed in the patient with intraluminal bleeding and
interventional radiology was employed for the other 2 patients. There was no hemorrhage-related
mortality or rebleeding, but the patient who underwent laparotomy developed sepsis. Endoscopy
may have no role in the initial management of delayed arterial hemorrhage
after pancreaticoduodenectomy. Interventional radiology is less invasive compared with laparotomy,
and may be considered as the first-line treatment for delayed arterial hemorrhage
in pancreaticoduodenectomy patients.
Chirurgia (Bucur). 2017 Jan-Feb;112(1):39-45. doi: 10.21614/chirurgia.112.1.39.
Intraluminal Postpancreatoduodenectomy Hemorrhage -

Last 5 Years Experience.
Vâlcea S, Beuran M, Vartic M; -.
Abstract
Background: One of the most significant complications following pancreaticoduodenectomy is

represented by postoperative hemorrhage.
AIM:
This study undertook an analysis of the cases that presented intraluminal bleeding of mechanical
gastrojejunal anastomosis following pancreatico duodenectomy (PD) in the last five
years. Methods: From January 2012 until January 2017, 84 consecutive
pancreaticoduodenectomies were performed and managed by the same surgical team. The
preferred procedure of reconstruction was Whipple (76 patients). The gastrojejunal anastomosis was
performed with Panther linear stapler GIA in all cases. ISGPS classification regarding
postpancreatectomy hemorrhage was used to evaluate severity. Results: Out of 84 consecutive PD,
a total of 7cases of intraluminal bleeding (8.33 %) were observed, detected on average on
postoperative day 4. Relaparotomy was inevitable in two patients. Three patients from the studied
group with intraluminal postpancreatectomy hemorrhage died. In the studied group there were no
cases of bleeding from the pancreatico-enteric or bilio-enteric anastomosis.
CONCLUSION:
Mechanical anastomosis might be questionable, severe hemorrhage demanding urgent
relaparotomy which is correlated with high mortality rates. Intralumenal postpancreatoduodenectomy
hemorrhage is a significant complication whose management depends on multiple factors and with a
potentially fatal outcome.
Hepatogastroenterology. 2003 Nov-Dec;50(54):2208-12.
Management of postoperative hemorrhage after

pancreatoduodenectomy.
Yoon YS1, Kim SW, Her KH, Park YC, Ahn YJ, Jang JY, Park SJ, Suh KS, Han JK, Lee KU, Park
YH.
Author information
Abstract
BACKGROUND/AIMS:
Hemorrhage after pancreatoduodenectomy is a severe, life-threatening complication. This study was
conducted to determine the guidelines appropriate for the prevention and management of
hemorrhagic complications.
METHODOLOGY:
We reviewed the medical records of 456 patients who had undergone pancreatoduodenectomy at
our hospital between 1991 and 2000.
RESULTS:
Significant postoperative bleeding occurred in 21 patients (4.6%). Early bleeding (within the 5th
postoperative day) caused by improper intraoperative hemostasis occurred in 5 of these cases; 3 of
whom were saved by prompt operation and one by conservative management. The other 16 cases
consisted of late bleeding (after the 5th postoperative day), of which 12 patients (75%) experienced
pancreatic leaks and 8 pseudoaneurysms of major arteries. "Sentinel bleeding" was evident in 8
cases. Angiographic embolization was performed in 8 cases, 7 of which were successful.
Reoperation was tried in 7 cases with complete hemostasis being achieved in 2. As a result, 15 of
21 patients obtained complete hemostasis and the mortality rate from hemorrhage was 28.6%
(6/21).
CONCLUSIONS:
Rapid decision-making is mandatory when bleeding stigmata such as pseudoaneurysm on CT and
sentinel bleeding are noted. Prompt operation for early bleeding and angiographic embolization for
late bleeding are recommended. In order to prevent hemorrhage after pancreatoduodenectomy,
meticulously performed hemostasis and the avoidance of pancreatic anastomotic leaks are
essential.
Zentralbl Chir. 2016 Dec;141(6):616-624. Epub 2016 Aug 8.
[Symptoms, Diagnostics, Treatment and Classification of

22 Patients with Postpancreatectomy Haemorrhage (PPH)
in a Series of 400 Consecutive Pancreatic Head Resections
and Pancreatectomies].
[Article in German]
Riediger H1, Krüger K2, Makowiec F3, Adam U1, Krueger CM1.
Author information
Abstract
Introduction: Postpancreatectomy haemorrhage (PPH) is a dangerous complication after

pancreatic resection. Patients and Methods: From 2006 to 2015, 400 consecutive pancreatic head
resections and pancreatectomies were performed and prospectively documented. This study
analysed incidence, treatment and outcome of patients with PPH. Results: Incidence of PPH was
5.5 % (n = 22). PPH occurred in a median of eight days after pancreatic surgery with an equal
frequency of symptoms being caused by gastrointestinal bleeding (n = 11) and abdominal bleeding
(n = 11). Postoperative pancreatic fistulas (POPF) were significantly more frequent in case of PPH
(45 % POPF in case of PPH vs. 20 % POPF in case of no PPH, p < 0.01). PPH was more frequent
after pancreatogastrostomy (8/70; 11 %) than after pancreatojejunostomy (11/281; 4 %; p = 0.01).
The majority of bleedings after pancreatogastrostomy came from the intragastric cut surface of the
pancreas. During the first week, relaparotomy was significantly more frequent (n = 5; 56 %) than in
late PPH (n = 1; 8 %; p = 0.01). In late PPH, interventions (angiography; n = 7, endoscopy; n = 4) were
more frequent. In 16 severe cases, surgical/interventional bleeding control (n = 12) or relevant
transfusions of more than 3 units of packed red blood cells (n = 4) were performed. Compared with
the whole group, mortality was significantly increased in case of PPH (13.6 % in case of PPH vs.
3.7 % in case of no PPH; p = 0.03). Conclusion: PPH is an episodic and potentially life-threatening
complication with an increased mortality rate, which is frequently associated with impaired healing of
the pancreatic anastomosis. Diagnostic investigation and treatment of PPH requires an experienced
surgical centre with a close cooperation with endoscopy and (interventional) radiology.
Ann Surg. 2007 Aug;246(2):269-80.
Postpancreatectomy hemorrhage: diagnosis and

treatment: an analysis in 1669 consecutive pancreatic
resections.
Yekebas EF1, Wolfram L, Cataldegirmen G, Habermann CR, Bogoevski D, Koenig AM, Kaifi
J, Schurr PG, Bubenheim M, Nolte-Ernsting C, Adam G, Izbicki JR.
Author information
Abstract
BACKGROUND:
To analyze clinical courses and outcome of postpancreatectomy hemorrhage (PPH) after major
pancreatic surgery.
SUMMARY BACKGROUND DATA:

Although PPH is the most life-threatening complication following pancreatic surgery, standardized
rules for its management do not exist.
METHODS:
Between 1992 and 2006, 1524 patients operated on for pancreatic diseases were included in a
prospective database. A risk stratification of PPH according to the following parameters was
performed: severity of PPH classified as mild (drop of hemoglobin concentration <3 g/dL) or severe
(>3 g/dL), time of PPH occurrence (early, first to fifth postoperative day; late, after sixth day),
coincident pancreatic fistula, intraluminal or extraluminal bleeding manifestation, and presence of
"complex" vascular pathologies (erosions, pseudoaneurysms). Success rates of interventional
endoscopy and angiography in preventing relaparotomy were analyzed as well as PPH-related
overall outcome.
RESULTS:
Prevalence of PPH was 5.7% (n = 87) distributed almost equally among patients suffering from
malignancies, borderline tumors, and focal pancreatitis (n = 47) and from chronic pancreatitis (n =
40). PPH-related overall mortality of 16% (n = 14) was closely associated with 1) the occurrence of
pancreatic fistula (13 of 14); 2) vascular pathologies, ie, erosions and pseudoaneurysms (12 of 14);
3) delayed PPH occurrence (14 of 14); and 4) underlying disease with lethal PPH found only in
patients with soft texture of the pancreatic remnant, while no patient with chronic pancreatitis died.
Conversely, primary severity of PPH (mild vs. severe) and the kind of index operation
(Whipple resection, pylorus-preserving partial pancreaticoduodenectomy, organ-preserving
procedures) had no influence on outcome of PPH. Endoscopy was successful in 3 from 15 patients
(20%), who had intraluminal PPH within the first or second postoperative day. "True," early
extraluminal PPH had uniformly to be treated by relaparotomy. Seventeen patients had "false," early
extraluminal PPH due to primarily intraluminal bleeding site from the pancreaticoenteric anastomosis
with secondary disruption of the anastomosis. From 43 patients subjected to angiography, 25
underwent interventional coiling with a success rate of 80% (n = 20). Overall, relaparotomy was
performed in 60 patients among whom 33 underwent surgery as first-line treatment, while 27 were
relaparotomied as rescue treatment after failure of interventional endoscopy or radiology.
CONCLUSION:
Prognosis of PPH depends mainly on the presence of preceding pancreatic fistula. Decision making
as to the indication for nonsurgical interventions should consider time of onset, presence of
pancreatic fistula, vascular pathologies, and the underlying disease.
ANZ J Surg. 2018 May;88(5):E435-E439. doi: 10.1111/ans.13976. Epub 2017 May 8.
Management of recurrent bleeding after

pancreatoduodenectomy.
Staerkle RF1, Gundara JS1, Hugh TJ1, Maher R2, Steinfort B2, Samra JS1.
Author information
Abstract
BACKGROUND:
Re-bleeding after management of a first haemorrhage following pancreatic surgery is an ever-
present danger and often presents diagnostic and management dilemmas.
METHODS:
All cases of post-pancreatectomy haemorrhage (PPH) following pancreatoduodenectomy were
identified from a tertiary referral, clinical database (April 2004-April 2013). Only those suffering a
second re-bleeding episode were included in the final case notes review.
RESULTS:
A total of 301 patients underwent pancreatoduodenectomy during the study period (most common
indication: pancreatic adenocarcinoma; 49.5%). Twenty-two (7.3%) patients suffered a PPH (five
early). Of these cases, three suffered a re-bleeding event (one mortality). Endoscopy, interventional
radiology and surgery were employed in each case.
CONCLUSION:
PPH presents major clinical challenges and is associated with significant morbidity and mortality.
Early detection of the site and type of bleeding are critical and multimodal therapy is usually
required. Interventional radiology techniques are making a major contribution to overall
management.
J Gastroenterol Hepatol. 2018 Dec 4. doi: 10.1111/jgh.14560. [Epub ahead of print]
Intra-abdominal hemorrhage following 739 consecutive

pancreaticoduodenectomy: Risk factors and treatments.
Lu JW 1,2, Ding HF1,2, Wu XN1,2, Liu XM1,2, Wang B1,2, Wu Z1,2, Lv Y1,2, Zhang XF1,2.
Author information
Abstract
BACKGROUND AND AIM:

Post-pancreaticoduodenectomy hemorrhage (PPH) is a potentially lethal complication. The objective
of this study was to explore the risk factors of PPH and to evaluate the treatment options.
METHODS:
Clinical data of 739 consecutive patients undergoing pancreaticoduodenectomy between 2009 and
2017 were collected from a prospectively maintained database. Univariate and multivariate analysis
was performed by logistic regression model to evaluate potential risk factors associated with early
and late PPH.
RESULTS:
The morbidity of PPH was 8.7% (64/739), while the mortality was 12.5% (8/64). Twenty-two (34.4%)
patients developed PPH within postoperative day 1 (early PPH) whereas 42 (65.6%) patients after
postoperative day 1 (late PPH). No significant risk factor was identified associated with early PPH,
whereas pancreatic duct diameter < 0.4 cm, and intra-abdominal complications, such as pancreatic
fistula, intra-abdominal abscess, and delayed gastric emptying, were independently correlated with
late PPH. There were 10 (15.6%) grade A, 28 (43.8%) grade B, and 26 (40.6%) grade C bleedings.
The bleeding sites were verified by endoscopy, angiography, and/or exploratory laparotomy in 23 of
54 (42.6%) patients with grade B or C hemorrhage. Seven out of nine (78%) patients with arterial
bleeding were cured by angiography and embolization, while 10 of 11 (90.9%) patients with
anastomotic, venous, or retroperitoneum bleeding were rescued by laparotomy. Ten patients with
grade A and 22 patients with grade B or C hemorrhage were treated successfully by blood
transfusion and hemostatic medications.
CONCLUSIONS:
Hemorrhage following pancreaticoduodenectomy is a common and lethal complication. Treatment
strategies should be tailored according to different etiologies.
© 2018 Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd.

Complications of Whipple Procedure

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1. https://www.ncbi.nlm.nih.

Hemorrhagic and Thromboembolic Complications after

© 2016 S. Karger AG, Basel.

Endovascular Treatment of Hepatic Artery

MATERIALS AND METHODS:

Post-pancreaticoduodenectomy hemorrhage: risk

Heterotopic pancreas autotransplantation with spleen for

Hemorrhagic complications after Whipple surgery:

Pseudoaneurysmal rupture of the common hepatic artery

Keywords: CT angiography, digital subtraction angiography, embolization, pancreatoduodenectomy, stent

Management of postoperative arterial hemorrhage after pancreato-biliary surgery should be done

Although mortality post-pancreaticoduodenectomy (PD) has decreased, morbidity rates continue

Systematic Review of Delayed Postoperative Hemorrhage after

Post-pancreaticoduodenectomy (PD) hemorrhage (PPH) is an uncommon but serious complication. This

Materials and Methods:

Sentinel bleeding after pancreaticoduodenectomy: a

MATERIAL AND METHODS:

[Delayed massive hemorrhage

Angiography is indicated for every sentinel bleed

Management of delayed postoperative hemorrhage

Diagnostic and therapeutic strategies to manage post-

Results of non-operative therapy for delayed hemorrhage

PATIENTS AND METHODS:

RESULTS AND DISCUSSION:

Delayed massive arterial hemorrhage

Late postpancreatectomy hemorrhage

Hemorrhage after pancreaticoduodenectomy: when is

Pancreatic leak related hemorrhage

Emergency management in patients with late hemorrhage

Delayed arterial hemorrhage

Delayed arterial hemorrhage is a rare complication of pancreaticoduodenectomy that is associated

Intraluminal Postpancreatoduodenectomy Hemorrhage -

Background: One of the most significant complications following pancreaticoduodenectomy is

Management of postoperative hemorrhage after

[Symptoms, Diagnostics, Treatment and Classification of

Introduction: Postpancreatectomy haemorrhage (PPH) is a dangerous complication after

Postpancreatectomy hemorrhage: diagnosis and

SUMMARY BACKGROUND DATA:

Management of recurrent bleeding after

Intra-abdominal hemorrhage following 739 consecutive

BACKGROUND AND AIM:

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