Delayed Post Pancreatectomy Hemorrhage: Incidence, Clinical Characteristics, Risk Factors and Management

Abstract

BackgroundPancreatic resection and especially pancreaticoduodenectomy (PD) is considered a complex operation, previously notorious for high perioperative morbidity and mortality rates. However, while the perioperative mortality of PD was over 15% in the 70's, it is now days less than 4% [1][2][3][4][5][6][7]. One of the most important reasons for this improvement is the greater experience of a limited number of surgeons who perform the procedure on a regular basis in high-volume referral centers [8][9][10][11]. Combined pancreatic resection and vascular reconstruction prevalence is rising. As expected, these patients have a higher morbidity and mortality rate in comparison to conventional PD (39.9% vs.33.3% and 5.7% vs.2.9%, respectively) [12].In spite of the impressive progress made in recent years in perioperative morbidity and mortality, a pancreatic fistula as a postoperative complication occurs in as high as 22% of cases [13]. Pancreatic fistulas can lead to sepsis and hemorrhage if not adequately drained. These complications are associated with mortality of 20 to 40%, prolonged hospitalization, and increased hospital expenses [14].Post pancreatectomy hemorrhage (PPH) is a term used for all bleeding episodes post pancreatic surgery. It is further divided according to the time of onset post operatively (delayed: >24 hrs postoperatively), location (intra/extraluminal, anastomotic origin) and severity of bleeding (severe PPH defined as hemoglobin drop>3 gr/ dl, hemodynamic instability or need for intervention) [15]. Prevalence of PPH is 5.5%, equally distributed among different indications for surgery (malignancies, borderline tumors, and focal pancreatitis). In an era of increased number of PD with vascular reconstruction, it is expected that the incidence of PPH will rise. In recent years an objective, universally accepted definition and clinical grading of PPH is adopted according to the International Study Group on Pancreatic surgery (ISGPS) [15].PPH-related overall mortality is 16-20% and raises to about 50% among the subgroup of DPPH secondary to pseudoaneurysm (PSA) or vascular erosion [16]. PSA exists when a normal arterial wall is replaced by fibrous tissue due to mechanical (iatrogenic) or chemical (by pancreatic juice) injury. This PSA may further cause a life-threatening bleeding.Clearly, some of the improvement in overall mortality after PD may be attributed to the post-operative management of complications. In this aspect, the considerable advances in invasive radiological techniques enable control of DPPH and reduce the need for re-laparotomy with its significant sequela [15].This study describes our experience in the management of DPPH with focus on risk factors and management. AbstractBackground: Delayed Post Pancreatectomy Hemorrhage (DPPH) is a devastating complication of pancreatic surgery, with a mortality rate approaching 50%. Clinical predictors and an effective management modality could improve patient outcome, but currently are not fully established.