Skip to main content

Advertisement

Log in

Systematic Review of Delayed Postoperative Hemorrhage after Pancreatic Resection

  • Review Article
  • Published:
Journal of Gastrointestinal Surgery Aims and scope

Abstract

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.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4

Similar content being viewed by others

References

  1. Trede M, Schwall G. The complications of pancreatectomy. Ann Surg 1988;207:39–47.

    Article  PubMed  CAS  Google Scholar 

  2. Tien YW, Lee PH, Yang CY, Ho MC, Chiu YF. Risk factors of massive bleeding related to pancreatic leak after pancreaticoduodenectomy. J Am Coll Surg 2005;201:554–9.

    Article  PubMed  Google Scholar 

  3. Miedema BW, Sarr MG, van Heerden JA, Nagorney DM, McIlrath DC, Ilstrup D. Complications following pancreaticoduodenectomy. Current management. Arch Surg 1992;127:945–9; discussion 949–50.

    Google Scholar 

  4. Yeo CJ, Cameron JL, Sohn TA, Lillemoe KD, Pitt HA, Talamini MA, Hruban RH, Ord SE, Sauter PK, Coleman J, Zahurak ML, Grochow LB, Abrams RA. Six hundred fifty consecutive pancreaticoduodenectomies in the 1990s: Pathology, complications, and outcomes. Annals of Surgery 1997;226:248–260.

    Article  PubMed  CAS  Google Scholar 

  5. van Berge Henegouwen MI, Allema JH, van Gulik TM, Verbeek PC, Obertop H, Gouma DJ. Delayed massive haemorrhage after pancreatic and biliary surgery. Br J Surg 1995;82:1527–31.

  6. Rumstadt B, Schwab M, Korth P, Samman M, Trede M. Hemorrhage after pancreatoduodenectomy. Ann Surg 1998;227:236–41.

    Article  PubMed  CAS  Google Scholar 

  7. Shankar S, Russell RC. Haemorrhage in pancreatic disease. Br J Surg 1989;76:863–6.

    Article  PubMed  CAS  Google Scholar 

  8. Kleespies A, Albertsmeier M, Obeidat F, Seeliger H, Jauch KW, Bruns CJ. The challenge of pancreatic anastomosis. Langenbeck's Archives of Surgery 2008;393:459–471.

    Article  PubMed  Google Scholar 

  9. Wente MN, Veit JA, Bassi C, Dervenis C, Fingerhut A, Gouma DJ, Izbicki JR, Neoptolemos JP, Padbury RT, Sarr MG, Yeo CJ, Buchler MW. Postpancreatectomy hemorrhage (PPH): an International Study Group of Pancreatic Surgery (ISGPS) definition. Surgery 2007;142:20–5.

    Article  PubMed  Google Scholar 

  10. Buchler MW, Friess H, Wagner M, Kulli C, Wagener V, Z'Graggen K. Pancreatic fistula after pancreatic head resection. Br J Surg 2000;87:883–9.

    Article  PubMed  CAS  Google Scholar 

  11. Wei HK, Wang SE, Shyr YM, Tseng HS, Tsai WC, Chen TH, Su CH, Wu CW, Lui WY. Risk factors for post-pancreaticoduodenectomy bleeding and finding an innovative approach to treatment. Dig Surg 2009;26:297–305.

    Article  PubMed  Google Scholar 

  12. Choi SH, Moon HJ, Heo JS, Joh JW, Kim YI. Delayed hemorrhage after pancreaticoduodenectomy. J Am Coll Surg 2004;199:186–91.

    Article  PubMed  Google Scholar 

  13. Liu C, Qiu YH, Luo XJ, Yi B, Jiang XQ, Tan WF, Yu Y, Wu MC. Treatment of massive pancreaticojejunal anastomotic hemorrhage after pancreatoduodenectomy. World J Gastroenterol 2009;15:1625–9.

    Article  PubMed  Google Scholar 

  14. Treckmann J, Paul A, Sotiropoulos GC, Lang H, Ozcelik A, Saner F, Broelsch CE. Sentinel bleeding after pancreaticoduodenectomy: a disregarded sign. J Gastrointest Surg 2008;12:313–8.

    Article  PubMed  Google Scholar 

  15. Yekebas EF, Wolfram L, Cataldegirmen G, Habermann CR, Bogoevski D, Koenig AM, Kaifi J, Schurr PG, Bubenheim M, Nolte-Ernsting C, Adam G, Izbicki JR. Postpancreatectomy hemorrhage: diagnosis and treatment: an analysis in 1669 consecutive pancreatic resections. Ann Surg 2007;246:269–80.

    Article  PubMed  Google Scholar 

  16. Yoon YS, Kim SW, Her KH, Park YC, Ahn YJ, Jang JY, Park SJ, Suh KS, Han JK, Lee KU, Park YH. Management of postoperative hemorrhage after pancreatoduodenectomy. Hepatogastroenterology 2003;50:2208–12.

    PubMed  Google Scholar 

  17. Balachandran P, Sikora SS, Raghavendra Rao RV, Kumar A, Saxena R, Kapoor VK. Haemorrhagic complications of pancreaticoduodenectomy. ANZ J Surg 2004;74:945–50.

    Article  PubMed  Google Scholar 

  18. Blanc T, Cortes A, Goere D, Sibert A, Pessaux P, Belghiti J, Sauvanet A. Hemorrhage after pancreaticoduodenectomy: when is surgery still indicated? Am J Surg 2007;194:3–9.

    Article  PubMed  Google Scholar 

  19. Boggi U, Del Chiaro M, Croce C, Amorese G, Signori S, Vistoli F, Di Candio G, Campatelli A, Morelli L, D'Imporzano S, Sgambelluri FA, Mosca I, Mosca F. Vascular complications of pancreatectomy. JOP 2007;8:102–13.

    PubMed  Google Scholar 

  20. Koukoutsis I, Bellagamba R, Morris-Stiff G, Wickremesekera S, Coldham C, Wigmore SJ, Mayer AD, Mirza DF, Buckels JA, Bramhall SR. Haemorrhage following pancreaticoduodenectomy: risk factors and the importance of sentinel bleed. Dig Surg 2006;23:224–8.

    Article  PubMed  CAS  Google Scholar 

  21. Makowiec F, Riediger H, Euringer W, Uhl M, Hopt UT, Adam U. Management of delayed visceral arterial bleeding after pancreatic head resection. J Gastrointest Surg 2005;9:1293–9.

    Article  PubMed  Google Scholar 

  22. Miura F, Asano T, Amano H, Yoshida M, Toyota N, Wada K, Kato K, Yamazaki E, Kadowaki S, Shibuya M, Maeno S, Furui S, Takeshita K, Kotake Y, Takada T. Management of postoperative arterial hemorrhage after pancreato-biliary surgery according to the site of bleeding: re-laparotomy or interventional radiology. J Hepatobiliary Pancreat Surg 2009;16:56–63.

    Article  PubMed  Google Scholar 

  23. Sato N, Yamaguchi K, Shimizu S, Morisaki T, Yokohata K, Chijiiwa K, Tanaka M. Coil embolization of bleeding visceral pseudoaneurysms following pancreatectomy: the importance of early angiography. Arch Surg 1998;133:1099–102.

    Article  PubMed  CAS  Google Scholar 

  24. Reber PU, Baer HU, Patel AG, Wildi S, Triller J, Buchler MW. Superselective microcoil embolization: treatment of choice in high-risk patients with extrahepatic pseudoaneurysms of the hepatic arteries. J Am Coll Surg 1998;186:325–30.

    Article  PubMed  CAS  Google Scholar 

  25. Sugimoto H, Kaneko T, Ishiguchi T, Takai K, Ohta T, Yagi Y, Inoue S, Takeda S, Nakao A. Delayed rupture of a pseudoaneurysm following pancreatoduodenectomy: Report of a case. Surgery Today 2001;31:932–935.

    Article  PubMed  CAS  Google Scholar 

  26. Otah E, Cushin BJ, Rozenblit GN, Neff R, Otah KE, Cooperman AM. Visceral artery pseudoaneurysms following pancreatoduodenectomy. Arch Surg 2002;137:55–9.

    Article  PubMed  Google Scholar 

  27. Santoro R, Carlini M, Carboni F, Nicolas C, Santoro E. Delayed massive arterial hemorrhage after pancreaticoduodenectomy for cancer. Management of a life-threatening complication. Hepatogastroenterology 2003;50:2199–204.

    PubMed  Google Scholar 

  28. Brodsky JT, Turnbull AD. Arterial hemorrhage after pancreatoduodenectomy. The ‘sentinel bleed’. Arch Surg 1991;126:1037–40.

    PubMed  CAS  Google Scholar 

  29. Tien YW, Wu YM, Liu KL, Ho CM, Lee PH. Angiography is indicated for every sentinel bleed after pancreaticoduodenectomy. Ann Surg Oncol 2008;15:185561.

    Article  PubMed  Google Scholar 

  30. de Castro SM, Kuhlmann KF, Busch OR, van Delden OM, Lameris JS, van Gulik TM, Obertop H, Gouma DJ. Delayed massive hemorrhage after pancreatic and biliary surgery: embolization or surgery? Ann Surg 2005;241:85–91.

    PubMed  Google Scholar 

  31. de Castro SM, Busch OR, Gouma DJ. Management of bleeding and leakage after pancreatic surgery. Best Pract Res Clin Gastroenterol 2004;18:847–64.

    PubMed  Google Scholar 

  32. Gervais DA, Fernandez-del Castillo C, O'Neill MJ, Hahn PF, Mueller PR. Complications after pancreatoduodenectomy: imaging and imaging-guided interventional procedures. Radiographics 2001;21:673–90.

    PubMed  CAS  Google Scholar 

  33. vanSonnenberg E, Wittich GR, Goodacre BW, Casola G, D'Agostino HB. Percutaneous abscess drainage: update. World J Surg 2001;25:362–9; discussion 370–2.

    Google Scholar 

  34. Turrini O, Moutardier V, Guiramand J, Lelong B, Bories E, Sannini A, Magnin V, Viret F, Blache JL, Giovannini M, Delpero JR. Hemorrhage after duodenopancreatectomy: impact of neoadjuvant radiochemotherapy and experience with sentinel bleeding. World J Surg 2005;29:212–6.

    Article  PubMed  Google Scholar 

  35. Kurosaki I, Hatakeyama K. Omental wrapping of skeletonized major vessels after pancreaticoduodenectomy. Int Surg 2004;89:90-4.

    PubMed  Google Scholar 

  36. Balladur P, Christophe M, Tiret E, Parc R. Bleeding of the pancreatic stump following pancreatoduodenectomy for cancer. Hepatogastroenterology 1996;43:268–70.

    PubMed  CAS  Google Scholar 

  37. Cullen JJ, Sarr MG, Ilstrup DM. Pancreatic anastomotic leak after pancreaticoduodenectomy: incidence, significance, and management. Am J Surg 1994;168:295–8.

    Article  PubMed  CAS  Google Scholar 

  38. Reber PU, Baer HU, Patel AG, Triller J, Buchler MW. Life-threatening upper gastrointestinal tract bleeding caused by ruptured extrahepatic pseudoaneurysm after pancreatoduodenectomy. Surgery 1998;124:114–5.

    Article  PubMed  CAS  Google Scholar 

  39. Noun R, Zeidan S, Tohme-Noun C, Smayra T, Sayegh R. Biliary ischemia following embolization of a pseudoaneurysm after pancreaticoduodenectomy. Journal of the Pancreas 2006;7:427–431.

    PubMed  Google Scholar 

  40. Burger T, Halloul Z, Meyer F, Grote R, Lippert H. Emergency stent-graft repair of a ruptured hepatic artery secondary to local postoperative peritonitis. J Endovasc Ther 2000;7:324–7.

    Article  PubMed  CAS  Google Scholar 

  41. Heiss P, Bachthaler M, Hamer OW, Piso P, Herold T, Schlitt HJ, Feuerbach S, Zorger N. Delayed visceral arterial hemorrhage following Whipple's procedure: minimally invasive treatment with covered stents. Ann Surg Oncol 2008;15:824–32.

    Article  PubMed  Google Scholar 

  42. Stoupis C, Ludwig K, Inderbitzin D, Do DD, Triller J. Stent grafting of acute hepatic artery bleeding following pancreatic head resection. Eur Radiol 2007;17:401–8.

    Article  PubMed  Google Scholar 

  43. McGraw JK, Patzik SB, Gale SS, Dodd JT, Boorstein JM. Autogenous vein-covered stent for the endovascular management of a superior mesenteric artery pseudoaneurysm. J Vasc Interv Radiol 1998;9:779–82.

    Article  PubMed  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Markus Schäfer.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Roulin, D., Cerantola, Y., Demartines, N. et al. Systematic Review of Delayed Postoperative Hemorrhage after Pancreatic Resection. J Gastrointest Surg 15, 1055–1062 (2011). https://doi.org/10.1007/s11605-011-1427-8

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11605-011-1427-8

Keywords

Navigation