title: Emergency management in patients with late hemorrhage after pancreatoduodenectomy for a periampullary tumor.
abstract: BACKGROUND
  The mortality rate due to late hemorrhage after surgery for periampullary tumors is high, especially in patients with anastomotic leakage. Patients usually require emergency intervention for late hemorrhage. In this study patients with late hemorrhage and their outcomes were analyzed. Furthermore, independent predictors for late hemorrhage, the need for emergency intervention, and type of intervention are reported.
  
  
  METHODS
  From a prospective database that includes 1,035 patients who underwent pancreatoduodenectomy for periampullary tumors between 1992 and 2012, patients with late hemorrhage (>24 h after index operation) were identified. Patient, disease-specific, and operation characteristics, type of intervention, and outcomes were analyzed. Emergency intervention was defined as surgical or radiological intervention in hemodynamically unstable patients.
  
  
  RESULTS
  Of the 47 patients (4.5 %) with late hemorrhage, pancreatic fistula was an independent predictor for developing late hemorrhage (OR 10.2). The mortality rate in patients with late hemorrhage was 13 % compared with 1.5 % in all patients without late hemorrhage. Twenty patients required emergency intervention; 80 % underwent primary radiological intervention and 20 % primary surgical intervention. Extraluminal location of the bleeding (OR 5.6) and occurrence of a sentinel bleed (OR 6.6) are indications for emergency intervention.
  
  
  CONCLUSIONS
  The type of emergency intervention needed for late hemorrhage is unpredictable. Radiological intervention is preferred, but if it fails, immediate change to surgical treatment is mandatory. This can be difficult to manage but possible when both radiological and surgical interventions are in close proximity such as in a hybrid operating room and should be considered in the emergency management of patients with late hemorrhage.
authors.affiliation: Department of Surgery, Academic Medical Centre, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands, a.p.jilesen@amc.uva.nl.
authors.forename: Anneke P J
authors.initials: AP
authors.lastname: Jilesen
authors.forename: Johanna A M G
authors.initials: JA
authors.lastname: Tol
authors.forename: Olivier R C
authors.initials: OR
authors.lastname: Busch
authors.forename: Otto M
authors.initials: OM
authors.lastname: van Delden
authors.forename: Thomas M
authors.initials: TM
authors.lastname: van Gulik
authors.forename: Els J M
authors.initials: EJ
authors.lastname: Nieveen van Dijkum
authors.forename: Dirk J
authors.initials: DJ
authors.lastname: Gouma
mesh_terms: D000230:Adenocarcinoma / Q000601:surgery*; D000368:Aged; D014670:Ampulla of Vater; D004067:Digestive System Neoplasms / Q000601:surgery*; D004621:Embolization, Therapeutic; D004630:Emergencies; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010185:Pancreatic Fistula / Q000209:etiology*; D016577:Pancreaticoduodenectomy / Q000009:adverse effects*; D019106:Postoperative Hemorrhage / Q000209:etiology / Q000401:mortality / Q000628:therapy*; D015642:Radiology, Interventional; D012189:Retrospective Studies; D015607:Stents