title: Delayed massive hemorrhage after pancreatic and biliary surgery: embolization or surgery?
abstract: OBJECTIVE
  To analyze the management of delayed massive hemorrhage (DMH) after major pancreatic and biliary surgery.
  
  
  BACKGROUND
  Despite a decreased mortality rate for pancreatic and biliary surgery, DMH is still an important cause of postoperative mortality. The aim of the present study was to analyze the management of DMH after pancreatic and biliary surgery, and specifically to assess the role of embolization and surgical intervention.
  
  
  METHODS
  The study group (SG) consisted of 1010 patients from 1994 to 2002 who underwent pancreatic or biliary surgery (cholecystectomy excluded). Patients from a previous study (1983-1993, n = 686) were used as a historical control group (HCG).
  
  
  RESULTS
  The incidence of DMH (SG 2.3% vs. HCG 3.2%) declined somewhat but did not differ significantly between both periods. The number of patients with a septic complication (SG 74% vs. HCG 50%) and a sentinel bleed (SG 78% vs. HCG 100%) before the onset of DMH did not differ significantly. Embolization (SG 2 of 2 patients vs. HCG 0 of 2 patients) was not used frequently. Successful outcome after surgical intervention (SG 14 of 16 patients vs. HCG 8 of 14 patients) and the surgical procedures performed to obtain hemostasis were comparable and overall mortality (SG 22% vs. HCG 29%) was comparable.
  
  
  CONCLUSIONS
  The incidence of DMH declined somewhat from 3.2% to 2.3% over the past years. Most patients present with septic complications and a sentinel bleed before onset of DMH. Despite general acceptance of embolization in our unit, it was used infrequently in patients with DMH. Aggressive surgical intervention was the treatment of choice in patients with DMH after pancreatic or biliary surgery.
authors.affiliation: Department of Surgery, Academic Medical Center, University of Amsterdam, The Netherlands.
authors.forename: Steve M M
authors.initials: SM
authors.lastname: de Castro
authors.forename: Koert F D
authors.initials: KF
authors.lastname: Kuhlmann
authors.forename: Olivier R C
authors.initials: OR
authors.lastname: Busch
authors.forename: Otto M
authors.initials: OM
authors.lastname: van Delden
authors.forename: Johan S
authors.initials: JS
authors.lastname: Laméris
authors.forename: Thomas M
authors.initials: TM
authors.lastname: van Gulik
authors.forename: Hugo
authors.initials: H
authors.lastname: Obertop
authors.forename: Dirk J
authors.initials: DJ
authors.lastname: Gouma
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001662:Biliary Tract Surgical Procedures / Q000379:methods; D013505:Digestive System Surgical Procedures / Q000009:adverse effects* / Q000379:methods; D004621:Embolization, Therapeutic / Q000379:methods*; D005260:Female; D006471:Gastrointestinal Hemorrhage / Q000175:diagnosis / Q000453:epidemiology / Q000209:etiology / Q000628:therapy*; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D010179:Pancreas / Q000601:surgery*; D018805:Sepsis / Q000209:etiology; D013997:Time Factors; D016896:Treatment Outcome