Hemorrhage after pancreaticoduodenectomy: when is surgery still indicated?

Background This study analyzed presentation and management of hemorrhage after pancreaticoduodenectomy (PD) to determine the respective role of surgery and embolization. Methods From January 1992 to March 2005, 411 patients underwent PD and were analyzed with regard to postoperative hemorrhage. Results Hemorrhage occurred in 27 patients (7%), either within the first 3 postoperative days (“early” hemorrhage, n = 11) or after day 8 (“delayed” hemorrhage, n = 16, including 4 with “sentinel” bleeding). At the time of bleeding, 12 patients (44%) (all with delayed hemorrhage) had associated abdominal complications. Two patients had successful conservative treatment. Two stable patients with pseudoaneurysm, diagnosed by computed tomography scan, underwent successful embolization. Four patients with active bleeding underwent unsuccessful angiography. Overall, 23 patients were reoperated on without any completion pancreatectomy, 3 rebled, and 3 (11%) died (including 2 with delayed hemorrhage). Conclusions Both embolization and surgery have a role in the management of hemorrhage after PD. For early hemorrhage, reoperation is appropriate. In case of sentinel bleeding, pseudoaneurysms can be detected by computed tomography scan and treated by embolization. For delayed active hemorrhage, reoperation is still indicated.