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Postpancreatectomy Hemorrhage

Postoperative complications represent one of the most debated topics in pancreatic surgery. Indeed, the rate of complications following pancreatectomy is among the highest in abdominal surgery, with morbidity ranging between 30 and 60%. They are often characterized by elevated clinical burden, with a consequent challenging postoperative management. Mortality rates can exceed 5%. The impact on patient recovery and hospital stay eventually leads to massive utilization of resources and increases costs for the health system. The International Study Group of Pancreatic Surgery (ISGPS) provides standardized definitions and clinically based classifications for the most common complications after pancreatectomy, including postoperative pancreatic fistula (POPF), post pancreatectomy hemorrhage (PPH), delayed gastric emptying (DGE), bile leakage, and chyle leak.

Post Pancreatectomy Hemorrhage
Despite its lower incidence compared with POPF with reported rates of 3–10% after pancreatectomy, PPH remains one of the major of postoperative complications, with mortality rates ranging from 30 to 50%. According to current ISGPS recommendations, PPH is classified in three grades (A, B, and C) based on two main criteria: timing of the hemorrhage and severity of the bleeding. The timing is dichotomized as early, occurring within 24 hours from the index surgery, and late, when it happens afterwards.

Management is tailored according to the clinical picture, the timing of onset, and the presumptive location. Early hemorrhage is generally due to either unsuccessful intraoperative hemostasis or to an underlying coagulopathy. The vast majority of patients are basically asymptomatic, with PPH having no influence on the postoperative course. However, when the bleeding is severe, re-laparotomy is recommended, with the aim of finding and controlling the source of bleeding. This approach usually guarantees an uneventful subsequent course. Late PPH is often challenging and the pathogenesis is diverse. Vascular erosion secondary to POPF or intraabdominal abscess, late failure of intraoperative hemostatic devices, arterial pseudoaneurysm, and intraluminal ulceration are some of the most common causes. In this setting, surgical access to the source of bleeding may be challenging. Angiography (if extraluminal) and endoscopy (if intraluminal) represent the primary approaches to treatment. Surgery is reserved for hemodynamically unstable patients and for those who present with deteriorating condition, multiorgan failure or sepsis. Given these assumptions, except for early mild events, contrast-enhanced abdominal CT is crucial in all cases of PPH, possibly allowing identification of the source and planning the management accordingly. Also, it should be noted that late massive hemorrhages may be preceded by mild self-limiting sentinel bleeds. A prompt abdominal CT scan aimed at excluding vascular lesions is therefore strongly recommended in these cases.

The incidence of complications following pancreatic resection remains high. The ISGPS established standardized definitions and clinical grading systems for POPF, PPH, DGE, and biliary and chyle leak. These classification systems have enabled unbiased comparisons of intraoperative techniques and management decisions. However, the management policies of these complications are most often driven by a patient’s condition and local surgical expertise and is not always based on the available high-level evidence. The development of high-volume specialized units with appropriate resources and multidisciplinary experience in complication management might further improve the evidence and the outcomes.

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