Optimizing the Management Strategies of Delayed Postpancreaticoduodenectomy Hemorrhage: Lessons From 2013 Consecutive...

To optimize the management strategies of delayed postpancreaticoduodenectomy hemorrhage (PPH) by evaluating data from a high-volume pancreatic center.

Delayed PPH is a potentially lethal complication. The management of delayed PPH remains controversial.

Patients who underwent pancreaticoduodenectomy between July 2018 and June 2023 were identified from an institutional database. The clinical scenarios, management, and outcomes of patients with delayed PPH (>5 days postoperatively) were analyzed.

Of the 2013 patients who underwent elective pancreaticoduodenectomy, 130 (6.5%) with delayed PPH were identified. The overall mortality was 15.4%. The success rates of endoscopy, angiographic intervention, and relaparotomy in treating delayed PPH were 54.5%, 56.5%, and 68.8%, respectively. For PPH from the hepatic arteries or their branches, complete blockade of the common or proper hepatic artery (C/PHA) was performed in 17 patients, either by coil embolization (n=7) or surgical ligation (n=10). Coil embolization of the C/PHA resulted in significant infarction of the left liver in 2 patients. No postoperative liver infarction occurred in patients who underwent ligation of the C/PHA during relaparotomy. Ten patients underwent suture repair of the C/PHA 13 times during relaparotomy. Arterial ligation achieved a significantly higher success rate of hemostasis than suture repair of the C/PHA during relaparotomy (100% vs 30.8%, P <0.001).

Angiography should be attempted first in managing hemodynamically stable delayed PPH. Arterial ligation was preferred for bleeding from the hepatic arteries during relaparotomy with minor consequences for the liver.