Postpancreatectomy Hemorrhage: Diagnosis and Treatment: An Analysis in 1669 Consecutive Pancreatic Resections

Although mortality after pancreatic surgery in most high-volume centers has decreased to less than 3%,1–3 morbidity still remains considerably high, ranging from 18% to 52%.4–9 The most frequent causes for morbidity are anastomotic insufficiencies (pancreatic, biliary, gastric/duodenal, and enteral), pancreatic fistulas, and delayed gastric emptying. Postpancreatectomy hemorrhage (PPH) is a less frequent, however, in some patients, devastating complication. Since both its pathophysiologic and clinical features may differ considerably, it is difficult to establish diagnostic and therapeutic algorithms for adequate management of PPH: 1) time of onset (early PPH occurring within 24 to 48 hours postoperatively versus delayed PPH after several days to weeks); 2) severity [(a) mild, (b) moderate, (c) severest, ie, life-threatening]; 3) intraluminal or extraluminal manifestation; 4) underlying disease (pancreatic carcinoma vs. chronic pancreatitis); 5) kind of index operation; and 6) a possible association to erosive vascular pathologies due to pancreatic fistula are factors that are important for estimating the prognosis of PPH. A customized risk analysis should precede individual decision-making. The armory of diagnostic and therapeutic means ranges from observant monitoring and fluid replacement, interventional procedures, ie, endoscopy and radiology, to surgical relaparotomy. Early bleeding within the immediate postoperative period is unlikely due to vascular erosions but rather a result of simple technical failures. In case of PPH in the abdominal cavity, no doubt exists that immediate relaparotomy is indicated. However, in case of early bleeding in the gastrointestinal tract, endoscopy may also be an option for interventionally treating bleeding sites located at the gastrojejunostomy or, if accessible, at the enteroenteric anastomosis. Because of the life-threatening potential of PPH, standardized rules with respect to its management are urgently needed. So far, in clinical routine, the decision about how to handle PPH is often arbitrary and is usually based on institutional or even individual experiences. The aim of the presented evaluation was therefore to “dissect” the heterogeneous causes of PPH. Onset of manifestations, clinical features, courses, and success rates of nonsurgical options, ie, interventional radiology and endoscopy, and surgical procedures for treatment of PPH were analyzed. Based on a 15-year institutional experience, we sought, in particular, to classify different bleeding types and suggest a diagnostic and therapeutic algorithm that may help to allocate patients to a customized therapy (Fig. 1). FIGURE 1. Suggested algorithm for treatment of early (A) and delayed (B) postpancreatectomy hemorrhage after major pancreatic surgery.