Evolution in the treatment of delayed postpancreatectomy hemorrhage: Surgery to interventional radiology

Objectives We summarized a single center's evolution in the management of postpancreatectomy hemorrhage (PPH) from surgical toward endovascular management. Methods Between 2003 and 2013, 337 patients underwent Whipple procedures. Using the International Study Group of Pancreatic Surgery (ISGPS) consensus definition, patients with PPH were identified and retrospectively analyzed for the presentation of hemorrhage, type of intervention, and 90-day mortality outcome measures. Results Management evolved from operative intervention alone, to combined operative and on-table angiographic intervention, to endovascular intervention alone. The prevalence of PPH was 3.0%. Delayed PPH occurred with a mean of 13.8 days. On angiography, visceral arteries affected were the gastroduodenal artery, hepatic artery, jejunal branches of the superior mesenteric artery, pancreaticoduodenal artery, and inferior phrenic artery. Ninety-day mortality for PPH was 20%. From early to recent experience, the mortality rate was 100% for operative intervention alone, 25% for combined operative and on-table angiographic intervention, and 0% for endovascular intervention alone. Conclusions Our 10-year experience supports current algorithms in the management of PPH. Key considerations include the recognition of the sentinel bleed, the presence of a pancreatic fistula, and the initial operative role of a long gastroduodenal artery stump with radiopaque marker for safe and effective embolization should PPH occur.