Late Postpancreatectomy Hemorrhage Research Articles

Development and Validation of a Model for Postpancreatectomy Hemorrhage Risk

Postpancreatectomy hemorrhage (PPH) due to postoperative pancreatic fistula (POPF) is a life-threatening complication after pancreatoduodenectomy. However, there is no prediction tool for early identification of patients at high risk of late PPH. To develop and validate a prediction model for PPH. This retrospective prognostic study included consecutive patients with clinically relevant POPF who underwent pancreatoduodenectomy from January 1, 2009, to May 20, 2023, at the University Hospital Mannheim (derivation cohort), and from January 1, 2012, to May 31, 2022, at the University Hospital Dresden (validation cohort). Data analysis was performed from May 30 to July 29, 2023. Clinical and radiologic features of PPH. Accuracy of a predictive risk score of PPH. A multivariate prediction model-the hemorrhage risk score (HRS)-was established in the derivation cohort (n = 139) and validated in the validation cohort (n = 154). A total of 293 patients (187 [64%] men; median age, 69 [IQR, 60-76] years) were included. The HRS comprised 4 variables with associations: sentinel bleeding (odds ratio [OR], 35.10; 95% CI, 5.58-221.00; P < .001), drain fluid culture positive for Candida species (OR, 14.40; 95% CI, 2.24-92.20; P < .001), and radiologic proof of rim enhancement of (OR, 12.00; 95% CI, 2.08-69.50; P = .006) or gas within (OR, 12.10; 95% CI, 2.22-65.50; P = .004) a peripancreatic fluid collection. Two risk categories were identified with patients at low risk (0-1 points) and high risk (≥2 points) to develop PPH. Patients with PPH were predicted accurately in the derivation cohort (C index, 0.97) and validation cohort (C index 0.83). The need for more invasive PPH management (74% vs 34%; P < .001) and severe complications (49% vs 23%; P < .001) were more frequent in high-risk patients compared with low-risk patients. In this retrospective prognostic study, a robust prediction model for PPH was developed and validated. This tool may facilitate early identification of patients at high risk for PPH.

The falciform/round ligament "flooring," an effective method to reduce life-threatening post-pancreatectomy hemorrhage occurrence.

Late post-pancreatectomy hemorrhage (PPH) represents the most severe complication after pancreatic surgery. We have measured the efficacy of major vessels "flooring" with falciform/round ligament to prevent life-threatening grade C late PPH after pancreaticoduodenectomy (PD) and distal pancreatectomy (DP). All consecutive patients who underwent PD and DP between 2013 and 2021 were retrospectively reviewed on a prospectively maintained database. The cohort was divided in two groups: "flooring" vs. "no flooring" method group. The "no flooring" group had omental flap interposition. Patient characteristics and operative and postoperative data including clinically relevant postoperative pancreatic fistula (CR-POPF), late PPH (grade B and C), and 90-day mortality were compared between the two groups. Two hundred and forty patients underwent pancreatic resections, including 143 PD and 97 DP. The "flooring" method was performed in 61 patients (39 PD and 22 DP). No difference was found between the two groups concerning severe morbidity, CR-POPF, delayed PPH, and mortality rate. The rate of patients requiring postoperative intensive care unit was lower in the "flooring" than in the "no flooring" method group (11.5% vs. 25.1%, p = 0.030). Among patients with grade B/C late PPH (n = 30), the rate of life-threatening grade C late PPH was lower in the "flooring" than in the "no flooring" method group (28.6% (n = 2/7) vs. 82.6% (n = 19/24), p = 0.014). Risk factor analysis showed that the "flooring" method was the only protective factor against grade C late PPH occurrence (p = 0.013). The "flooring" method using the falciform/round ligament should be considered during pancreatectomies to reduce the occurrence of life-threatening grade C late PPH.

Management and outcomes of pseudoaneurysms presenting with late hemorrhage following pancreatic surgery: A six-year experience from a tertiary care center.

Late hemorrhage following pancreatic surgery is associated with significant morbidity and mortality. Pseudoaneurysm (PSA) is an important source of late hemorrhage, which is effectively and safely managed by embolization. We aim to retrospectively review the outcomes of embolization for pseudoaneurysms causing late post-pancreatectomy hemorrhage over a period ofsix-years at our tertiary care center. Between 2014 and 2020, 616 pancreatic surgeries were performed and 25 patients had late hemorrhage (occurring > 24hours post-operatively). The clinical parameters related to late hemorrhage, associated complications, embolization details, treatment success and their short-and long-term outcomes were analyzed. Sixteen of 25 patients had PSA on digital subtraction angiography. Embolization was performed in these patients with technical and clinical success rates of 94.1% and 100%, respectively. Compared to patients without PSA, patients with PSA had significant hemoglobin drop (2.5g/dL vs. 1.5g/dL, p = 0.01), higher incidence of sentinel bleed (50% vs. 11.1%, p = 0.05) and lower requirement for surgery for bleeding (0% vs. 44.4%, p = 0.02). Clincally relevant postoperative pancreatic fistula and bile leak were seen in 72% and 52% of patients, respectively. Eight of these embolized patients died due to sepsis. The long-term outcome was good, once the patients were discharged. Late hemorrhage after pancreatic surgery was associated with high mortality due to complications such as pancreatic fistula and bile leak. Sentinel bleeding was an important clinical indicator of PSA. Angiographic embolization is safe and effective without any adverse short or long-term outcomes.

Diagnosis and management of postpancreatectomy hemorrhage: A single-center experience of consecutive 1,096 pancreatoduodenectomies

Background/objectivesThis study aimed to assess the outcomes and characteristics of post-pancreatectomy hemorrhage (PPH) in over 1000 patients who underwent pancreatoduodenectomy (PD) at a high-volume hepatopancreaticobiliary center. MethodsThis retrospective study analyzed consecutive patients who underwent PD from 2010 through 2021. PPH was diagnosed and managed using our algorithm based on timing of onset and location of hemorrhage. ResultsOf 1096 patients who underwent PD, 33 patients (3.0%) had PPH; incidence of in-hospital and 90-day mortality relevant to PPH were one patient (3.0%) and zero patients, respectively. Early (≤24 h after surgery) and late (>24 h) PPH affected 9 patients and 24 patients, respectively; 16 patients experienced late-extraluminal PPH. The incidence of postoperative pancreatic fistula (p < 0.001), abdominal infection (p < 0.001), highest values of drain fluid amylase (DFA) within 3 days, and highest value of C-reactive protein (CRP) within 3 days after surgery (DFA: p < 0.001) (CRP: p = 0.010) were significantly higher in the late-extraluminal-PPH group. The highest values of DFA≥10000U/l (p = 0.022), CRP≥15 mg/dl (p < 0.001), and incidence of abdominal infection (p = 0.004) were identified as independent risk factors for PPH in the multivariate analysis. Although the hospital stay was significantly longer in the late-extraluminal-PPH group (p < 0.001), discharge to patient's home (p = 0.751) and readmission rate within 30-day (p = 0.765) and 90-day (p = 0.062) did not differ between groups. ConclusionsStandardized management of PPH according to the onset and source of hemorrhage minimizes the incidence of serious deterioration and mortality. High-risk patients with PPH can be predicted based on the DFA values, CRP levels, and incidence of abdominal infections.

Conduits in Vascular Pancreatic Surgery: Analysis of Clinical Outcomes, Operative Techniques, and Graft Performance.

We analyze successes and failures of pushing the boundaries in vascular pancreatic surgery to establish safety of conduit reconstructions. Improved systemic control from chemotherapy in pancreatic cancer is increasing the demand for surgical solutions of extensive local vessel involvement, but conduit-specific data are scarce. We identified 63 implanted conduits (41% autologous vessels, 37% allografts, 18% PTFE) in 56 pancreatic resections of highly selected cancer patients between October 2013 and July 2020 from our prospectively maintained database. Assessed parameters were survival, perioperative complications, operative techniques (anatomic and extra-anatomic routes), and conduit patency. For vascular reconstruction, 25 arterial and 38 venous conduits were utilized during 39 pancreatoduodenectomies, 14 distal pancreatectomies, and 3 total pancreatectomies. The median postoperative survival was 2 years. A Clavien-Dindo grade ≥IIIa complication was apparent in 50% of the patients with a median Comprehensive Complication Index of 29.6. The 90-day mortality in this highly selected cohort was 9%. Causes of mortality were conduit related in 3 patients, late postpancreatectomy hemorrhage in 1 patient, and early liver metastasis in 1 patient. Image-based patency rates of conduits were 66% and 45% at postoperative days 30 and 90, respectively. Our perioperative mortality of vascular pancreatic surgery with conduits in the arterial or venous system is 9%. Reconstructions are technically feasible with different anatomic and extra-anatomic strategies, while identifying predictors of early conduit occlusion remains challenging. Optimizing reconstructed arterial and venous hemodynamics in the context of pancreatic malignancy will enable long-term survival in more patients responsive to chemotherapies.

Late postpancreatectomy hemorrhage from the gastroduodenal artery stump into an insufficient hepaticojejunostomy: a case report

BackgroundMortality after elective pancreatic surgery in modern high-volume centers is very low. Morbidity remains high, affecting 20–40% of patients. Late postpancreatectomy hemorrhage is a rare but potentially lethal complication. The exceptionality in our case lies in the underlying mechanism of its clinical presentation. It is a demonstration of the difficulties associated with finding the source of bleeding in late postpancreatectomy hemorrhage.Case presentationAn 82-year-old White female was diagnosed with a periampullary malignancy and underwent pancreatoduodenectomy. Postoperatively, the patient suffered from an anastomotic leak in the hepaticojejunostomy, which was treated with percutaneous pigtail drains in the abdomen and in the biliary tract. On the fourth postoperative week she presented blood in both drains and in her stool. Given our knowledge about the biliary anastomotic leak, this presentation led us to suspect an intraluminal source (biliary tract or gastrojejunostomy) with blood leaking through the insufficient hepaticojejunostomy into the abdominal cavity. Upper tract endoscopy and computed tomography angiography were, however, unremarkable. Further investigation with conventional angiography identified the bleeding source at the gastroduodenal artery stump, which was successfully coiled. Hence, the gastroduodenal artery stump was bleeding into the insufficient hepaticojejunostomy, filling up the biliary tree and the small intestine. After coiling of the artery, the remainder of the postoperative care was uneventful.ConclusionPostpancreatectomy hemorrhage presents a major clinical challenge after pancreatoduodenectomy, with significant morbidity and high risk for mortality. The treating physician must be alert and active in the investigation and treatment of the bleeding source to ensure a successful outcome.

Analysis of risk factors for hemorrhage and related outcome after pancreatoduodenectomy in an intermediate-volume center.

Precise risk factors for bleeding after pancreatoduodenectomy (PD) need to be further explored. We aimed to identify which variables were associated with the risk of post-pancreatectomy hemorrhage (PPH) and benchmark the PPH rate and related outcome in our intermediate-volume center with the current literature. We retrospectively analyzed 183 PD records. We investigated the association between PPH and a number of pre-surgical (age, body mass index, bilirubin plasma level, gender, American Society of Anesthesiologists classification (ASA) and smoking status, vascular hypertension), surgical (technique, additional organ resection, occlusion of the stump) and post-surgical (pancreatic fistula, bile leak and abscess development) risk factors with multivariable regression models. PPH episodes were classified and graded according to the International Study Group of Pancreatic Surgery. The overall PPH risk was 19.6%. Specific PPH mortality was 16.6%. Occurrence of PPH was increased in male patients (RR = 2.4, p = 0.001), with ASA ≥ 3 (RR = 2.1, p = 0.009) and hypertension (RR = 1.8, p = 0.04). Active smoking was protective (RR = 0.26, p = 0.001). Among postoperative factors, only pancreatic fistula increased the risk (RR = 1.6, p = 0.034). Early PPH was associated with the type of surgical reconstruction (RR 4.02, 95% CI 1.41-11.44, p = 0.009) and late PPH with pancreatic fistula (RR 2.88, 95% CI 1.06-7.83, p = 0.038). For grade C PPH, the impact of pancreatic fistula was greater (RR = 2.8, p = 0.04). Pancreatic fistula plays a crucial role in the pathogenesis of PPH. In addition, male gender, ASA ≥ 3 and hypertension increase the risk of PPH, while smoking appears protective. The PPH risk and subsequent consequences are at an acceptable rate in an intermediate-volume center.

Two forms of one complication: Late erosive and nonerosive postpancreatectomy hemorrhage following laparoscopic pancreaticoduodenectomy.

Postpancreatectomy hemorrhage (PPH) remains a rare but lethal complication following laparoscopic pancreaticoduodenectomy (LPD) in the modern era of advanced surgical techniques. The main reason for early PPH (within 24 hours following surgery) has been found to be a failure of hemostasis during the surgical procedure. The reasons for late PPH tend to be variate. Positive associations have been identified between late PPH and intraabdominal erosive factors such as postoperative pancreatic fistula, bile leakage, gastrointestinal fistula, and intraabdominal infection. Still, some patients suffer PPH who do not have these erosive factors. The severity of bleeding and clinical prognosis of erosive and nonerosive PPH following LPD is different.We analyzed the electronic clinical records of 33 consecutive patients undergoing LPD and experiencing one or more episodes of hemorrhage after postoperative day 1 in this study. All patients received an LPD with standard lymphadenectomy. The patient's hemorrhage-related information was extracted, such as interval from surgery to bleeding, presentation, bleeding site, severity, management, and clinical prognosis. Based on our clinical practice, we proposed a treatment strategy for these 2 forms of late PPH following LPD.Of these 33 patients, 8 patients (24.24%) developed nonerosive bleeding, and other 25 patients (75.76%) suffered from postoperative hemorrhage caused by various intraabdominal erosive factors. The median interval from the LPD surgery to postoperative hemorrhage for both groups was 11 days, and no significant differences were found (P = .387). For patients with erosive bleeding, most (60%) underwent their episodes of bleeding on postoperative days 5 to 14. For patients with nonerosive bleeding, most (75%) began postoperative hemorrhage 2 weeks after surgery, and 50% of these patients had bleeding between postoperative days 20 and 30. In the present study, 64% (16/25) of patients with erosive bleeding and 87.5% (7/8) of patients with nonerosive bleeding had internal bleeding. The fact that 90% (9/10) of all gastrointestinal bleeding patients had intraabdominal erosive factors indicated strong relationships between gastrointestinal hemorrhage and these erosive factors. The bleeding sites were detected in most patients, except for 4 patients who received conservative treatments. For patients with erosive bleeding, the most common bleeding site detected was the pancreatic remnant (43.48%); others included the hepatic artery (39.13%), splenic artery (13.04%), and left gastric artery (4.35%). For patients with nonerosive bleeding, the most common bleeding site was the hepatic artery (83.33%), and the 2nd most frequent site was the splenic artery (16.67%). No hemorrhage from pancreaticojejunal anastomosis occurred in the patients with nonerosive bleeding. Statistical significance was noted between these 2 groups in hemorrhage severity (P = .012), management strategies (P = .001), rebleeding occurrence (P = .031), and prognosis outcome (P = .010). The patients with intraabdominal erosive factors tended to have a higher risk of grade C bleeding (68.00%) than that of their nonerosive bleeding counterparts (12.50%). As for treatment strategy for postoperative bleeding, the favorable method to manage nonerosive bleeding was conservative and endovascular treatments if the patients’ hemodynamics was stable. All these nonerosive bleeding patients survived. On the contrary, 22 patients (88.00%) in the erosive bleeding group had a 2nd surgical procedure, and the mortality was 56.00%. In this group, 2 patients received conservative therapy due to the demand of their family and expired. One patient underwent endovascular treatment and had another episode of hemorrhage, finally dying from multi-organ failure. No patients in the nonerosive bleeding group suffered from rebleeding after complete hemostasis, and 44.00% of patients with erosive bleeding underwent a 2nd episode of postoperative bleeding.Erosive and nonerosive PPH are 2 forms of this lethal complication following LPD. Their severity of bleeding, rebleeding rate, and treatment strategy are different. Patients with erosive factors tend to have a higher incidence of grade C bleeding, rebleeding, and mortality. Factors influencing treatment protocols for PPH include the existence of intraabdominal erosive factors, patient hemodynamics, possibility to detect the bleeding site during endovascular treatment, and surgeon's preference. The performance of endovascular treatment with stent repair for managing postoperative hemorrhage after LPD depends on the discovery of the bleeding site. Surgery should be reserved as an emergent and final choice to manage PPH.

Transcatheter Arterial Embolization for Late Postpancreatectomy Hemorrhage of Unusual Origin (Dorsal Pancreatic Artery): A Report of Three Cases

: Postpancreatectomy hemorrhage (PPH) is a rare but serious complication that can lead to death. Although the best treatment option for PPH remains controversial, transcatheter arterial embolization (TAE) has recently been introduced as a treatment with safety and efficacy, showing low morbidity and mortality, especially in late PPH (> 24 h after surgery). The most common location for PPH is the gastroduodenal artery stump; however, hemorrhage may occur from unusual sources, such as the dorsal pancreatic artery (DPA), which is often difficult to detect on angiography. Herein, the authors report three cases of delayed PPH from the DPA, occurring after a Frey procedure in one case and after pylorus-preserving pancreaticoduodenectomy in the other two. All patients were successfully treated using TAE. Although the involved artery was not identified on the first angiography in two patients, rebleeding was successfully managed by repeated endovascular procedures. Therefore, a careful and repetitive approach, based on awareness of the various causes of PPH, could increase the success rate of TAE.

AB052. P023. Diagnosis and management of postpancreatectomy hemorrhage: a systematic review and meta-analysis

Background: Late postpancreatectomy hemorrhage (PPH) is a rare, yet potentially lethal complication after a pancreatic resection. The objective of this study was to compare clinical outcomes of different invasive interventions for late PPH.

Late postpancreatectomy hemorrhage: Predictive factors of morbidity and mortality after percutaneous endovascular treatment.

The objective of this study was to evaluate the effectiveness of endovascular treatment in patients presenting with late hemorrhage after pancreatectomy (LPPH). Between 2008 and 2012, 53 percutaneous arterial procedures were performed in 42 patients with LPPH. There were 27 men and 15 women (mean age, 61.8 years±14.5 [SD]; range: 19-81 years). Clinical and technical success along with frequency of complications associated with the use of different endovascular techniques in patients with and without arterial anatomical variation were assessed. Clinical success was observed in 35/42 patients (85%). The technical success was 37.5% in patients with anatomical variation versus 82.8% for those with modal anatomy (P=0.003). Repeat bleeding (P=0.029), complications (P=0.013) and mortality (P=0.045) were more frequent in patients with variation of celiac artery than in those with modal anatomy. For hepatic and gastroduodenal artery stump bleeding, the rate of complications was higher (60%) in the group treated by hepatic artery embolization (P=0.028) by comparison with gastroduodenal artery stump selective embolisations or treatments by covered stent. A significant difference in mortality rate was found between patients with anatomical variations of celiac artery (36.4%) and those with normal anatomy (6.5%) (P=0.032). Percutaneous endovascular treatment is effective in patients presenting with LPPH. The presence of an anatomical variation of the celiac artery increases the rate of complications and mortality in patients with LPPH.

Late postpancreatectomy hemorrhage after pancreaticoduodenectomy: is it possible to recognize risk factors?

Post-pancreatectomy hemorrhage is one of the most common complications after pancreaticoduodenectomy. 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. 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. 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. 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.

2:12 PM, Abstract No. 45 - Transcatheter arterial embolization for late postpancreatectomy hemorrhage: risk factors associated with mortality

2:12 PM, Abstract No. 45 - Transcatheter arterial embolization for late postpancreatectomy hemorrhage: risk factors associated with mortality

Pancreatic Resections: Frequency, Safety and Usefulness of Postoperative Interventional Radiology

Context Interventional radiology (IR) have increased for the first-line management of postoperative complications after pancreatic resections. Objective To evaluate frequency, safety and usefulness of IR. Methods Patients with postoperative complications after pancreatic resections were analyzed for the use of IR procedures. Patients in which IR was performed were compared with those in which IR was not performed, regarding type of pancreatic resections, diagnosis, post-operative mortality and morbidity according Clavien-Dindo classification, post­operative pancreatic fistula (POPF), post­pancreatectomy hemorrhage (PPH), bile leakage, reoperations rate and length of hospital stay (LOS). Results Two-hundred and ninety patients were recorded: 182 (72.8%) experienced postoperative complications, 67 (36.8%) Clavien grade ≥3. IR was performed in 37 cases (20.3%): in 28 (75.7%) a percutaneous drainage (PD) of an abdominal fluid collection, in 8 (21.6%) a transhepatic biliary drainage (PTBD) and an arterial embolization (AE) in 3 cases (8.1%). IR was performed 14±6.7 days after surgery, with technical success in all cases and clinical success in 75.7%. Re-operation rate after IR was 13.5%, thus re-operations were avoided in 32 (86.5%) cases. Mortality after IR was 16.2%; 4 (66.7%) patients died after a re-laparotomy post-IR. Mean LOS was 18.3±14.4 days. There were no statistical differences between the IR group and the non-IR group regarding type of resection, pathological diagnosis, postoperative mortality and reoperation rate. Patients with clinically relevant POPF and bile leak were treated with IR more frequently than without IR (P<0.001 and P=0.009, respectively). Patients with late PPH were treated more frequently with IR (P=0.030), as well as patients with PPH grade C (P=0.029). Patients with a Clavien score ≥3, were treated significantly more frequently with IR (P<0.001). Finally, patients treated with IR had a significant longer LOS than those in the non-IR group (37.5±23.4 vs . 18.7±11.7 days; P<0.001). Conclusions IR procedures are feasible and safe especially for postoperative pancreatic fistula and bile leak. They are useful because promptly can resolve several life-threatening complications avoiding re-operations.

Superselective Embolization for the Management of Postpancreatectomy Hemorrhage: A Single-Center Experience in 25 Patients

PurposeTo evaluate the efficacy of superselective embolization in patients with late postpancreatectomy hemorrhage (PPH). Materials and MethodsBetween January 2002 and July 2010, 25 patients (19 men) with suspected late PPH (> 24 hours after the operation) were evaluated. The primary study endpoint was technical success, defined as complete angiographic occlusion of the site of hemorrhage. Secondary study endpoints were multidetector computed tomography (CT) and angiographic findings regarding accurate detection of the site of hemorrhage, persistence of hemorrhage, or occurrence of rebleeding during clinical follow-up. ResultsMultidetector CT was performed before the intervention in 17 (68%) patients with detection of hemorrhage in 15 (88%) patients. The site of hemorrhage was detected in 23 (92%) of 25 patients by angiography. Four (17%) patients required a superselective catheter position. Embolization was attempted in all 23 patients with angiographically visible hemorrhage. In three (13%) patients, embolization could not be performed because a superselective catheter position was not achievable. Technical success was 83% (19 patients). In one patient, hemostasis was not achieved by embolization. Minor complications occurred in three (13%) patients. No major complications occurred. Three patients with technically successful embolization (16%) had a second episode of bleeding during follow-up and required repeat embolization 5–23 days after the procedure. The 30-day mortality rate was 20%. ConclusionsSuperselective embolization is a technically and clinically effective procedure in patients with late PPH. Diagnostic angiography should be performed with a superselective microcatheter position to detect the bleeding site effectively.

Critical appraisal of the International Study Group of Pancreatic Surgery (ISGPS) consensus definition of postoperative hemorrhage after pancreatoduodenectomy

Postpancreatectomy hemorrhage (PPH) is one of the most serious complications after pancreatoduodenectomy (PD). This study analyzed and validated the International Study Group of Pancreatic Surgery (ISGPS) definition of PPH and aimed to identify risk factors for early (<24 h) and late PPH. Patients who underwent PD for pancreatic head tumors between 2001 and 2008 were included and complications were prospectively recorded. Factors associated with PPH were assessed by uni- and multivariate analysis. Complete datasets were available for 796 patients. Classic and pylorus-preserving PD was performed in 13.8% and 86.2% of the patients, respectively. According to the ISGPS definition, PPH occurred in 29.1% of the cases (232 of 796 patients): 4.8% grade A, 15.2% grade B, and 9.2% grade C. The definition is based largely on surrogate markers (e.g., transfusion requirement) that are affected by other critical illnesses and more than 97% of patients with mild PPH had no clinical signs of bleeding. The need for postoperative intensive care as well as the incidence of pancreatic fistula, relaparotomy, and mortality rates significantly increased from grades A to C. Thirty-seven patients (4.6%) required interventional (endoscopy or angiography) and/or relaparotomy for PPH. Relaparotomy for PPH was performed in 3.1% of all patients. Independent risk factors for early PPH were preoperative anemia (hemoglobin, <11 mg/dl) and multivisceral resection while advanced age, chronic renal insufficiency, increased blood loss, and long operation time were associated with late PPH. The ISGPS definition of PPH is feasible and applicable but produces a high rate of false positive mild PPH cases. The different grades still significantly correlate with relevant outcome variables, thus the definition discriminates postoperative courses, but a minor modification of the definition of mild PPH is suggested. The new results further demonstrate the need to optimize preoperative anemia and chronic renal insufficiency.

Falciform ligament in pancreatoduodenectomy for protection of skeletonized and divided vessels

Pancreatic fistula, which is one of the main causes of late postpancreatectomy hemorrhage (PPH), is a common complication of pancreatoduodenectomy (PD). It may erode the anastomosis site and vascular wall in its vicinity, resulting in pseudoaneurysm formation and/or the rupture of major vessels. To protect the vessels near the area for pancreaticojejunostomy from potential pancreatic fistula, we have adopted a surgical option by which such vessels are separated from the pancreaticojejunostomy using a pedicled falciform ligament. We reviewed 36 patients who underwent PD that included this option. After the PD was completed (before reconstructions), the pedicled falciform ligament was spread widely on the major vessels exposed during resection, and was fixed to the surrounding retroperitoneal connective tissue. These procedures enabled the complete separation of these vessels from the pancreaticojejunostomy. The mobilization and placement of the falciform ligament in the space between the pancreaticojejunostomy and the major vessels were successfully carried out without any complications. Although ten (28%) patients developed pancreatic fistula and three (8%) developed intraabdominal infection, none of the patients developed late PPH. The present surgical option is technically simple and easy, and may be an effective prophylactic measure against late PPH following PD.