Arterial hemorrhage after pancreatoduodenectomy. The 'sentinel bleed'

Experienced centers report reduced operative mortality after pancreatoduodenectomy for cancer, but significant complications continue to occur in as many as 25% of patients. Anastomotic disruption leads to sepsis in the pancreatic bed where major vascular structures have been exposed by regional lymphadenectomy, creating a setting for arterial erosion or ligature slough and massive hemorrhage. Dehiscence of the pancreatojejunostomy is a particular risk. We treated five patients with arterial hemorrhage after pancreatoduodenectomy, all of whom had had "sentinel" bleeding from the abdominal drains or gastrointestinal tract. Results of endoscopy were misleading in two patients. Three of five patients were saved by prompt recognition, early operation, and, in one instance, angiographic embolization. Sentinel bleeding after pancreatoduodenectomy indicates local sepsis and probable anastomotic dehiscence. Recognition of its significance and prompt response may prevent exsanguination.