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Incidence and Contemporary Management of Delayed Bleeding Following Pancreaticoduodenectomy

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Abstract

Background

Delayed bleeding after pancreaticoduodenectomy (PD) is a life-threatening complication. However, the optimal management remains unclear. We summarize our experience of the management of delayed bleeding after PD and define the outcomes associated with different types of management.

Methods

All patients who underwent a PD between January 1987 and June 2020 at Johns Hopkins University were retrospectively reviewed. Delayed bleeding was defined as bleeding on or after postoperative day 5 following PD. Incidence, outcomes, and trends were reported.

Results

Among the 6201 patients that underwent PD, delayed bleeding occurred in 130 (2.1%) at a median of 12 days (IQR: 9, 24) postoperation. The pattern of bleeding was classified as intraluminal (51.5%), extraluminal (40.8%), and mixed (7.7%). A clinically relevant postoperative pancreatic fistula and an intraabdominal abscess preceded the delayed bleeding in 43.1% and 31.5% of cases, respectively. Arterial pseudoaneurysm or bleeding from peripancreatic vessels was the most common reason (54.6%) with the gastroduodenal artery being the most common source (18.5%). Endoscopy, angiography, and reoperation were performed as a first-line approach in 35.4%, 52.3%, and 6.2% of patients, respectively. The overall mortality was 16.2% and decreased over the study period (p < 0.01).

Conclusions

Delayed bleeding following PD remains a life-threatening complication. The most common location of delayed bleeding is from the gastroduodenal artery. Angiography with embolization should be the initial approach for urgent bleeding with surgical re-exploration reserved for unstable patients or failed control of bleeding after interventional angiography or endoscopy.

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Authors and Affiliations

  1. Department of Surgery, Johns Hopkins University School of Medicine, 1800 Orleans Street, Baltimore, MD, 21287, USA

    Joseph R. Habib, Shanshan Gao, Elie Ghabi, William Burns, Richard Burkhart, John L. Cameron, Jin He & Kelly J. Lafaro

  2. Department of Surgery, SNMU, Seoul, South Korea

    Ahn Joon Young

  3. Department of Surgery, OSU, Columbus, OH, USA

    Aslam Ejaz

  4. Department of Surgery, NYU Langone Health, New York, NY, USA

    Christopher L. Wolfgang

  5. Division of Interventional Radiology, Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD, USA

    Robert Liddell, Christos Georgiades & Kelvin Hong

  6. Department of Surgery, Northwell Health, Manhasset, NY, USA

    Matthew Weiss

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  1. Joseph R. Habib
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Correspondence to Jin He or Kelly J. Lafaro.

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Habib, J.R., Gao, S., Young, A.J. et al. Incidence and Contemporary Management of Delayed Bleeding Following Pancreaticoduodenectomy. World J Surg 46, 1161–1171 (2022). https://doi.org/10.1007/s00268-022-06451-x

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