title: Late post pancreatectomy haemorrhage. Risk factors and modern management.
abstract: BACKGROUND
  Current management of late post-pancreatectomy haemorrhage in a university hospital.
  
  
  OBJECTIVE
  Haemorrhage after pancreaticoduodenectomy is a serious complication. We report on risk factors and outcome following management by radiological intervention.
  
  
  METHODS
  Tertiary care centre in Scotland.
  
  
  METHODS
  Sixty-seven consecutive patients who underwent pancreaticoduodenectomy.
  
  
  METHODS
  All pancreaticoduodenectomies over a 3-year period were reviewed. International Study Group on Pancreatic Surgery (ISGPS) definition of post-pancreatectomy haemorrhage was used.
  
  
  METHODS
  Endpoints were incidence of haemorrhage, pancreaticojejunal anastomosis leak, methicillin-resistant Staphylococcus aureus (MRSA) infection and mortality.
  
  
  RESULTS
  Seven patients (10.4%) developed post-pancreatectomy haemorrhage out of 67 pancreaticoduodenectomies. Median age was 71 years. All post-pancreatectomy haemorrhage were late onset (median 23 days; range: 3-35 days), extraluminal and ISGPS grade C. Post-pancreatectomy haemorrhage arose from hepatic artery (n=4), superior mesenteric artery (n=1), jejunal artery (n=1), and splenic artery (n=1). Angiographic treatment was successful in all patients by embolisation (n=5) or stent grafting (n=2). Pancreatic fistula rate was similar in post-pancreatectomy haemorrhage and "no-haemorrhage" groups (57.1% vs. 40.0%; P=0.440); MRSA infection was significantly higher in post-pancreatectomy haemorrhage group (57.1% vs. 16.7%; P=0.030). Mortality from post-pancreatectomy haemorrhage despite successful haemostasis was 42.9%. Univariate and multivariate analysis identified MRSA infection as a risk factor for post-pancreatectomy haemorrhage.
  
  
  CONCLUSIONS
  CT angiogram followed by conventional catheter angiography is effective for treatment of late extraluminal post-pancreatectomy haemorrhage. MRSA infection in the abdominal drain fluid increases its risk and therefore aggressive treatment of MRSA and high index of suspicion are indicated.
authors.affiliation: Ninewells Hospital and Medical School, Dundee, United Kingdom. f.polignano@nhs.net
authors.forename: Pandanaboyana
authors.initials: P
authors.lastname: Sanjay
authors.forename: Ali
authors.initials: A
authors.lastname: Fawzi
authors.forename: Jennifer L
authors.initials: JL
authors.lastname: Fulke
authors.forename: Christoph
authors.initials: C
authors.lastname: Kulli
authors.forename: Iain S
authors.initials: IS
authors.lastname: Tait
authors.forename: Iain A
authors.initials: IA
authors.lastname: Zealley
authors.forename: Francesco M
authors.initials: FM
authors.lastname: Polignano
mesh_terms: D000230:Adenocarcinoma / Q000000981:diagnostic imaging / Q000401:mortality* / Q000601:surgery*; D000368:Aged; D000369:Aged, 80 and over; D018281:Cholangiocarcinoma / Q000000981:diagnostic imaging / Q000401:mortality / Q000601:surgery; D005260:Female; D006801:Humans; D016015:Logistic Models; D008297:Male; D055624:Methicillin-Resistant Staphylococcus aureus; D008875:Middle Aged; D018358:Neuroendocrine Tumors / Q000000981:diagnostic imaging / Q000401:mortality / Q000601:surgery; D010185:Pancreatic Fistula / Q000401:mortality / Q000628:therapy; D010190:Pancreatic Neoplasms / Q000000981:diagnostic imaging / Q000401:mortality* / Q000601:surgery*; D016577:Pancreaticoduodenectomy / Q000009:adverse effects* / Q000706:statistics & numerical data; D019106:Postoperative Hemorrhage / Q000401:mortality* / Q000628:therapy*; D012307:Risk Factors; D012606:Scotland / Q000453:epidemiology; D013203:Staphylococcal Infections / Q000401:mortality / Q000628:therapy; D013530:Surgical Wound Infection / Q000401:mortality / Q000628:therapy; D013997:Time Factors; D014057:Tomography, X-Ray Computed