title: Post pancreaticoduodenectomy haemorrhage: outcome prediction based on new ISGPS Clinical severity grading.
abstract: OBJECTIVE & BACKGROUND DATA: Mortality following pancreatoduodenectomy (PD) has fallen below 5%, yet morbidity remains between 30 and 50%. Major haemorrhage following PD makes a significant contribution to this ongoing morbidity and mortality. The aim of the present study was to validate the new International Study Group of Pancreatic Surgery (ISGPS) Clinical grading system in predicting the outcome of post pancreaticoduodenectomy haemorrhage (PPH).
  
  
  METHODS
  Between January 1998 and December 2007 a total of 458 patients who underwent Whipple's pancreaticoduodenectomy in our department were analysed with regard to haemorrhagic complications. The onset, location and severity of haemorrhage were classified according to the new criteria developed by an ISGPS. Risk factors for haemorrhage, management and outcome were analysed.
  
  
  RESULTS
  Severe PPH occurred in 14 patients (3.1%). Early haemorrhage (<24 hours) was recorded in five (36%) patients, and late haemorrhage (>24 hours) in nine (64%) patients. As per Clinical grading of ISGPS 7 (50%) belongs to Grade C and 7 (50%) belongs to Grade B. Haemostasis was attempted by surgery in 10 (71%) patients; angioembolisation was successful in two (14%) and endotherapy in one (7%) patient. The overall mortality is 29%(n=4). Age >60 years (p=0.02), sentinel bleeding (p=0.04), pancreatic leak (p=0.04) and ISGPS Clinical grade C (p=0.02) were associated with increased mortality.
  
  
  CONCLUSIONS
  Early haemorrhage was mostly managed surgically with better outcome when endoscopy is not feasible. Late haemorrhage is associated with high mortality due to pancreatic leak and sepsis. ISGPS Clinical grading of PPH is useful in predicting the outcome.
authors.affiliation: Department of Surgical Gastroenterology and Center for G.I. Bleed & Division of Hepato Biliary Pancreatic Diseases, Government Stanley Medical College Hospital, The Tamilnadu Dr. M.G.R. Medical University, Chennai, Tamilnadu, India. stanleygastro@yahoo.com
authors.forename: G
authors.initials: G
authors.lastname: Rajarathinam
authors.forename: D G
authors.initials: DG
authors.lastname: Kannan
authors.forename: V
authors.initials: V
authors.lastname: Vimalraj
authors.forename: A
authors.initials: A
authors.lastname: Amudhan
authors.forename: S
authors.initials: S
authors.lastname: Rajendran
authors.forename: D
authors.initials: D
authors.lastname: Jyotibasu
authors.forename: T G
authors.initials: TG
authors.lastname: Balachandar
authors.forename: S
authors.initials: S
authors.lastname: Jeswanth
authors.forename: P
authors.initials: P
authors.lastname: Ravichandran
authors.forename: R
authors.initials: R
authors.lastname: Surendran