Postpancreatectomy Hemorrhage: Early and Late

Abstract

Postpancreatectomy hemorrhage (PPH) should be a rare complication, but when it occurs, it is a major cause of morbidity and mortality after pancreaticoduodenectomy (PD). PPH can be divided into early (first 24 h) or late (usually 10 days or more after PD or distal pancreatectomy). Early PPH is caused by technical failure of appropriate hemostasis or an underlying perioperative coagulopathy. Late PPH is typically caused by complications of the operation, most commonly a pancreatic leak (which is the etiology of pseudoaneurysm formation). Early PPH can be prevented by direct ligation of the inferior pancreaticoduodenal arteries (IPDA) arising from the superior mesenteric artery (SMA); mass ligation of the tissue to the right of the SMA can result in bleeding from the IPDAs within the first 24 h after PD. Late PPH can be prevented by the use of a pedicled falciform ligament flap to protect the vessels from possible pancreatic fistula and related fluid collections. The occurrence of a sentinel bleed is a key sign before the onset of delayed/late PPH.