title: Multimedia manuscript. Endoscopic clipping of a post-Whipple pancreatic bleed.
abstract: BACKGROUND
  Bleeding after pancreaticoduodenectomy most often occurs from the gastro- or duodeno-jejunal anastomosis. Bleeding at the pancreatic surface would be the most difficult to treat because it typically requires surgical resection of the pancreatic remnant-a surgery that has significant morbidity and mortality. Data that describe the role of endoscopy in the management of pancreaticojejunostomy bleeding are limited.
  
  
  METHODS
  We present the case of a 69-year-old man who had massive upper gastrointestinal bleeding on postoperative day 2 after a pyloric sparing Whipple procedure for cholangiocarcinoma. We endoscopically approached this massive upper gastrointestinal bleed by understanding the postsurgical anatomy to consider all of the potential bleeding sources: duodenojejunostomy, hepaticojejunstomy, and the pancreaticojejunostomy. Using a pediatric colonoscope with water jet capabilities, active bleeding could be seen originating from the cut pancreatic surface. Complete hemostasis was achieved after placement of two clips. We clipped again two clays later due to a minor rebleeding episode. We repeated endoscopy on postoperative day 6 for surveillance of the site. All clips were in place and there was no evidence of bleeding. The patient did well without recurrent bleeding and was discharged home on postoperative day 7. Six-month follow-up showed no recurrent bleeding episodes or development of fistulas.
  
  
  CONCLUSIONS
  Endoscopic treatment of a bleeding site on the pancreatic surface of a pancreaticojejunostomy can be successful during the immediate postoperative period. Such an attempt at endoscopic hemostasis may prevent the need for completion pancreatectomy.
authors.affiliation: Division of Gastroenterology, Department of Medicine, Veterans Affairs Palo Alto Health Care System, Stanford University School of Medicine, 3801 Miranda Avenue, GI-111, Palo Alto, CA 94304, USA.
authors.forename: Tonya
authors.initials: T
authors.lastname: Kaltenbach
authors.forename: Sherry
authors.initials: S
authors.lastname: Wren
authors.forename: Lana
authors.initials: L
authors.lastname: Schumacher
authors.forename: Roy
authors.initials: R
authors.lastname: Soetikno
mesh_terms: D000368:Aged; D001650:Bile Duct Neoplasms / Q000601:surgery; D001653:Bile Ducts, Intrahepatic / Q000601:surgery; D018281:Cholangiocarcinoma / Q000601:surgery; D020685:Colonoscopes; D016099:Endoscopy, Gastrointestinal / Q000379:methods*; D016558:Hemostasis, Endoscopic / Q000295:instrumentation / Q000379:methods*; D006801:Humans; D008297:Male; D016577:Pancreaticoduodenectomy; D019106:Postoperative Hemorrhage / Q000601:surgery*; D013525:Surgical Instruments