title: Sentinel bleeding after pancreaticoduodenectomy: a disregarded sign.
abstract: BACKGROUND
  Delayed massive hemorrhage induced by pancreatic fistula after pancreaticoduodenectomy is a rare but life-threatening complication. The purpose of this study was to analyze the clinical course of patients with late hemorrhage, with or without sentinel bleeding, to better define treatment options in the future.
  
  
  METHODS
  From April 1998 to December 2006, 189 pancreaticoduodenectomies were performed. Eleven patients, including two patients referred from other hospitals, were treated with delayed massive hemorrhage occurring 5 days or more after pancreaticoduodenectomy. Sentinel bleeding was defined as minor blood loss via surgical drains or the gastrointestinal tract with an asymptomatic interval until development of hemorrhagic shock. The clinical data of patients with bleeding episodes were analyzed retrospectively.
  
  
  RESULTS
  Eight of the 11 patients had sentinel bleeding, and seven of them had it at least 6 h before acute deterioration. Seven out of 11 patients died, five out of eight with sentinel bleeding. No differences could be detected between patients with or without sentinel bleeding before delayed massive hemorrhage. The only difference found was that non-surviving patients were significantly older than surviving patients. Delayed massive hemorrhage is a common cause of death after pancreaticoduodenostomy complicated by pancreatic fistula formation. The observation of sentinel bleeding should lead to emergency angiography and dependent from the result to emergency relaparotomy to increase the likelihood of survival.
authors.affiliation: Department of General, Visceral, and Transplantation Surgery, University Hospital of Essen, Essen, Germany. j.treckmann@gmx.net
authors.forename: Jürgen
authors.initials: J
authors.lastname: Treckmann
authors.forename: Andreas
authors.initials: A
authors.lastname: Paul
authors.forename: Georgios C
authors.initials: GC
authors.lastname: Sotiropoulos
authors.forename: Hauke
authors.initials: H
authors.lastname: Lang
authors.forename: Arzu
authors.initials: A
authors.lastname: Ozcelik
authors.forename: Fuat
authors.initials: F
authors.lastname: Saner
authors.forename: Christoph E
authors.initials: CE
authors.lastname: Broelsch
mesh_terms: D000368:Aged; D016063:Blood Loss, Surgical; D004621:Embolization, Therapeutic; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010185:Pancreatic Fistula / Q000150:complications* / Q000209:etiology; D010190:Pancreatic Neoplasms / Q000601:surgery; D016577:Pancreaticoduodenectomy / Q000009:adverse effects* / Q000379:methods; D050500:Pancreatitis, Chronic / Q000601:surgery; D019106:Postoperative Hemorrhage / Q000175:diagnosis* / Q000209:etiology; D012771:Shock, Hemorrhagic / Q000209:etiology; D013997:Time Factors