World Journal of Surgery

, Volume 38, Issue 9, pp 2438–2447 | Cite as

Emergency Management in Patients with Late Hemorrhage after Pancreatoduodenectomy for a Periampullary Tumor

  • Anneke P. J. JilesenEmail author
  • Johanna A. M. G. Tol
  • Olivier R. C. Busch
  • Otto M. van Delden
  • Thomas M. van Gulik
  • Els J. M. Nieveen van Dijkum
  • Dirk J. Gouma



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.


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.


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.


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.


Pancreatic Fistula Stent Graft Coil Embolization Emergency Intervention Univariable Analysis 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


Conflict of interest

The authors have no conflicts of interest to disclose.


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Copyright information

© Société Internationale de Chirurgie 2014

Authors and Affiliations

  • Anneke P. J. Jilesen
    • 1
    Email author
  • Johanna A. M. G. Tol
    • 1
  • Olivier R. C. Busch
    • 1
  • Otto M. van Delden
    • 2
  • Thomas M. van Gulik
    • 1
  • Els J. M. Nieveen van Dijkum
    • 1
  • Dirk J. Gouma
    • 1
  1. 1.Department of SurgeryAcademic Medical CentreAmsterdamThe Netherlands
  2. 2.Department of RadiologyAcademic Medical CentreAmsterdamThe Netherlands

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