One discussion this week involved etiologies of postpancreatectomy hemorrhage.

Reference: Yekebas EF, et al. Postpancreatectomy hemorrhage: diagnosis and treatment: an analysis in 1669 consecutive pancreatic resections. Annals of Surgery. 2007 Aug;246(2):269-280. doi:10.1097/01.sla.0000262953.77735.db

Summary: With the purpose of creating algorithms for managing postpancreatectomy hemorrhage (PPH), Yekebas et al (2007) restrospectively analyzed more than 1669 pancreatic resections conducted between 1992 and 2006.  They concluded that the prognosis of postpancreatectomy hemorrhage (PPH) is primarily dependent on the presence of “preceding pancreatic fistula” (p.269).

Overall PPH-related mortality was 16% (n=14) and associated closely with:

• Occurrence of pancreatic fistula: Fistula-related PPH was significantly higher in those with pancreatic remnants of soft texture (carcinoma, NET, borderline tumors, etc) (66%) than those with a firm glandular texture due to chronic pancreatitits (7.5%) (p.279).
• Vascular pathologies (erosions and pseudoaneurysms)
• Delayed PPH occurrence: Fatal outcomes occurred predominately in late-onset PPH (after sixth postoperative day); early-onset PPH (until fifth postoperative day) typically carried a good prognosis.
• Sentinel bleeding: Fistula-delayed PPH was closely related to sentinel bleeding. A timely diagnosis of sentinel bleeding could prevent mortality, for “its presence considerably worsened prognosis of delayed PPH with an increase of morality from 38% associated with fistula-related PPH to 57% in patients who additionally had sentinel bleed” (p.279).

Severity of PPH (mild vs severe) and type of index operation (Classic whipple, pylorus-preserving partial pancreaticoduodenectomy, organ-preserving procedures) had no influence on PPH outcomes.